Hypertensive Emergency
BP > 180/120 mmHg + acute end-organ damage (encephalopathy, stroke, ACS, aortic dissection, AKI, retinal papilledema); reduce MAP by 20–25% in 1st hour.
Acute Pericarditis
Pleuritic chest pain relieved by sitting forward; friction rub; diffuse ST elevations + PR depressions in limb/precordial leads with PR elevation in aVR.
Cardiac Tamponade
Beck's triad (Hypotension, JVD, Muffled heart sounds) + Pulsus paradoxus (> 10 mmHg inspiratory drop in SBP); emergent pericardiocentesis.
First-Line Pericarditis Rx
High-dose NSAIDs (Ibuprofen / Indomethacin) + Colchicine for 3 months to prevent recurrent pericarditis; avoid steroids in acute post-MI pericarditis.
Hypertensive Urgency vs. Emergency Protocols
| Category | Diagnostic Criteria | Target Blood Pressure Reduction | Preferred Pharmacologic Agents |
|---|---|---|---|
| Hypertensive Urgency | SBP > 180 and/or DBP > 120 mmHg WITHOUT evidence of acute target-organ damage | Gradual oral lowering over 24–48 hours; do NOT rapidly lower acutely (risk of cerebral hypoperfusion) | Oral Captopril, Labetalol, Clonidine, or Amlodipine; outpatient follow-up in 24–72 hours |
| Hypertensive Emergency | Severe BP elevation (> 180/120) WITH acute end-organ injury (encephalopathy, acute MI, pulmonary edema, aortic dissection) | Reduce MAP by maximum 20–25% in first hour, then to 160/100 over next 2–6 hours (Exception: Aortic dissection mandates rapid drop to SBP < 120 within 20 minutes) | IV Nicardipine, IV Labetalol, IV Clevidipine, IV Fenoldopam, or IV Nitroprusside (watch cyanide toxicity) |
Acute Pericarditis vs. Cardiac Tamponade vs. Constrictive Pericarditis
| Syndrome | Pathognomonic Physical Findings | ECG & Diagnostic Hallmark | Primary Intervention |
|---|---|---|---|
| Acute Pericarditis | Sharp, pleuritic, retrosternal chest pain; improves sitting up and leaning forward; pericardial friction rub | Diffuse concave ST elevation and PR segment depression across multiple leads; reciprocal PR elevation in lead aVR | NSAIDs + Colchicine (first-line); Colchicine reduces recurrence by 50% |
| Cardiac Tamponade | Beck's Triad: 1. Hypotension, 2. Elevated JVP, 3. Muffled/distant heart sounds; Pulsus paradoxus > 10 mmHg | Electrical alternans (beat-to-beat variation in QRS amplitude); echo shows right atrial and right ventricular diastolic collapse | Emergent bedside pericardiocentesis under ultrasound guidance; IV crystalloid bolus to maintain preload |
| Constrictive Pericarditis | Right heart failure symptoms (ascites, peripheral edema, hepatomegaly); Kussmaul sign (paradoxical JVP rise on inspiration); pericardial knock | CXR/CT: pericardial calcification; Echo: septal bounce ('shudder') during early diastole; prominent 'y' descent on JVP | Diuretics for symptomatic relief; definitive cure via surgical pericardiectomy ('pericardial stripping') |
OMM Board Correlate: Phrenic Nerve & Thoracic Inlet Drainage
- Phrenic Nerve (C3–C5): The fibrous and parietal pericardium are innervated by the phrenic nerves. Somatosomatic reflexes cause referred pain to the ipsilateral trapezius ridge and neck (C3–C5 dermatomes) in acute pericarditis.
- Cervical Facet & Diaphragm Mechanics: Treating C3–C5 somatic dysfunction and releasing myofascial tension in the scalenes normalizes phrenic irritation and optimizes diaphragmatic excursion.
Board Traps & Common Distractors
- In Acute Aortic Dissection presenting as a hypertensive crisis, beta-blockers (IV Esmolol or Labetalol) MUST be administered BEFORE vasodilators (Nitroprusside); giving vasodilators first triggers reflex sympathetic tachycardia, increasing aortic wall shear stress (dP/dt) and propagating dissection.
- In Cardiac Tamponade, positive-pressure mechanical ventilation is hazardous because it elevates intrathoracic pressure, decreases venous return, and precipitates acute pulseless electrical activity (PEA) arrest.
- Avoid systemic corticosteroids in acute pericarditis following myocardial infarction (Dressler syndrome / peri-infarction pericarditis); corticosteroids impair myocardial scar formation and increase the risk of free-wall rupture.