Hypertensive Crisis

The clinician managing hypertensive crisis performs comprehensive evaluation for secondary causes, selects target-specific treatment strategies, prescribes IV and transition oral antihypertensives, and coordinates ICU care. Secondary hypertension workup is essential in any hypertensive emergency, particularly in young patients or treatment-resistant cases. Renovascular hypertension (renal artery stenosis) is assessed by renal artery duplex ultrasound, CT angiography, or MR angiography; elevated plasma renin activity and aldosterone suggest RAAS activation. Pheochromocytoma is screened with plasma free metanephrines (most sensitive test) and 24-hour urine catecholamines/metanephrines. Primary hyperaldosteronism (Conn syndrome) is screened with aldosterone-to-renin ratio (above 30 with plasma aldosterone above 15 ng/dL suggests diagnosis). Cushing syndrome is screened with 24-hour urine cortisol, overnight dexamethasone suppression test, or late-night salivary cortisol. Coarctation of the aorta presents with upper extremity hypertension, lower extremity hypotension, and rib notching on CXR. The clinician integrates these findings to determine etiology-specific management, prescribes multi-drug antihypertensive regimens for discharge, addresses adherence barriers, and arranges appropriate follow-up. For resistant hypertension (uncontrolled on 3 drugs including a diuretic), the clinician considers adding spironolactone (PATHWAY-2 trial demonstrated superiority of spironolactone as fourth-line agent), evaluates...