Introduction

Hypertension is a chronic illness that affects approximately 46% of adults in the United States. The chief complaint of elevated blood pressure accounts for 0.3-0.6% of all ED visits [1], and 25-36% of those patients will have a hypertensive emergency, which is defined by the American Heart Association as a systolic blood pressure (SBP) over diastolic blood pressure (DBP) of greater than 180/110-120mmHg, with evidence of end-organ damage [2]. This is distinct from hypertensive urgency, in which individuals may have severely elevated blood pressure without signs of end-organ damage. Regardless of the terminology, the emphasis should be placed on mitigating the potential sequelae of acute or severe hypertension rather than the number itself. Signs and symptoms of end-organ damage in hypertensive emergency include acute pulmonary edema, stroke, cardiac ischemia, congestive heart failure, encephalopathy, and acute kidney injury. In a large systematic review from 2023, ischemic stroke and pulmonary edema were the most common sequelae, representing 24% and 28% of patients with hypertensive emergency, respectively [3].

A hypertensive emergency carries a high hospitalization and mortality rate, making early identification and management critical. In a 2021 cross-sectional study at a tertiary care center, 40% of patients deemed to have a hypertensive emergency were admitted and found to have 1-year mortality rates of 26.9% [4]. In a 2023 systematic review of clinical outcomes of hypertensive emergency, 84% of all patients diagnosed with hypertensive emergency were admitted, and 10% died during their hospitalization [3]. Those presenting with hypertensive emergency are typically adults >60 years old, male, and carry diagnoses of hypertension or comorbidities such as diabetes, chronic kidney disease, or cardiovascular disease. Medication non-adherence, sympathomimetic drug use, and dietary indiscretion are common triggers for hypertensive emergency in these patients.

Only approximately 23% of hypertensive emergencies occur in patients with no known diagnosis of hypertension [5]. We present a rare case in which a young patient without a prior diagnosis or any known risk factors presented to our emergency department and was found to be in a hypertensive emergency.