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cardio.hypertensive-emergency.core.v1

Hypertensive emergency

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

2026-05-14 shard-06-cardio-acute depth pass — full §5.5 contract walk: 9-step regimen ladder reorganised around 8 end-organ phenotypes (encephalopathy, dissection, flash pulm edema, ACS, severe pre-eclampsia/eclampsia, AKI on admission, sympathetic crisis, scleroderma renal crisis) + oral transition step; 5 setting playbooks (ed, icu, inpatient, transition, outpatient); 4 setting transitions (admit/escalation/de_escalation/discharge); 12 severity triggers; 5 calculators band-mapped (map, ckd_epi_2021, corrected_ca, cha2ds2vasc, ich_score); evidence PMID array expanded 5 → 28; LR seed extended to 30 distinct pairs covering Klompas dissection + Goldstein stroke + Panju AMI + Wang HF + Maisel BNP + Lichtenstein BLUE + Lenders pheo + Funder aldo + ACOG 222 pre-eclampsia; ROS seed authored (12 ROS items). Co-located _design-brief.md + _research-bundle.md authored at src/lib/dossiers/cardio.hypertensive-emergency.core.v1._{design-brief,research-bundle}.md per §5.5 contract items 1-2. Engine-specific panel src/components/panels/cardio/hypertensive-emergency-panel.tsx already wired into cardio-acute-panel-router; not modified in this pass. Manifest cites 2025 ACC/AHA HTN, 2024 ESC/ESH, AHA/ASA 2022 ICH, ACC/AHA 2022 Aortic, ACOG 222 2019, ACEP 2024 Policy. 2026-05-24 citation+RxCUI safety sweep: every PMID + RxCUI live-verified (PubMed esummary / RxNav property.json). Former placeholders resolved — ACC/AHA 2025 HTN → 40811497, ESC/ESH 2024 → 39210715, PAGE-PE placeholder replaced by HI-DOSE SCAPE 36327753. 5 wrong drug RxCUIs corrected (labetalol/esmolol/furosemide/hydralazine/phenoxybenzamine) and ~17 fabricated trial PMIDs corrected. Future depth pass: add a syndrome-specific protocol entry (HTN-emergency-by-syndrome) into clinical-tools-registry.ts; current pathway loosely overlaps with protocol.cardiogenic_shock + protocol.ich + protocol.stroke.

Entry points (3)

  • vital_abnormality
    SBP >180 and/or DBP >120 (ACC/AHA 2017; Whelton 2018)
    sbp_gt_180
  • symptom
    Headache, chest pain, dyspnea, vision change, focal deficit, seizure (Vaughan JAMA 2000)
    end_organ_signs
  • imaging
    CT head ICH / aortic dissection / pulmonary edema (AHA/ASA 2022; ACC/AHA 2022)
    imaging_end_organ

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Pregnancy, age extremes alter agent selection (ACOG 2019; ACC/AHA 2017)
  • sbprequired
    vital • used at RED_FLAGS
    Defines emergency threshold ≥180 + titration target (ACC/AHA 2017; Whelton 2018)
  • dbprequired
    vital • used at RED_FLAGS
    Defines emergency threshold ≥120 + titration target (ACC/AHA 2017; Whelton 2018)
  • hrrequired
    vital • used at TREATMENT
    Aortic dissection target HR <60 before vasodilator (ACC/AHA 2022 Aortic)
  • neuro_deficitrequired
    symptom • used at RED_FLAGS
    Stroke / ICH / hypertensive encephalopathy / PRES (Vaughan JAMA 2000; AHA/ASA 2022)
  • chest_back_pain
    symptom • used at RED_FLAGS
    ACS, dissection, pulmonary edema (ACC/AHA 2017; Vaughan JAMA 2000)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI — hypertensive AKI / scleroderma renal crisis (ACC/AHA 2017)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac end-organ damage (ACC/AHA 2017; Vaughan JAMA 2000)
  • lactate
    lab • used at INITIAL_WORKUP
    Tissue perfusion in shock states (ESC/ESH 2023)
  • cxr
    imaging • used at INITIAL_WORKUP
    Pulmonary edema / mediastinal widening (ACC/AHA 2017)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    LVH, ischemia (ACC/AHA 2017; ESC/ESH 2023)
  • pregnancy
    history • used at CONTEXT
    Eclampsia/preeclampsia targets + MgSO4 + delivery curative (ACOG 2019; Magee NEJM 2022)
  • cocaine_or_meth
    history • used at CONTEXT
    Sympathomimetic crisis — phentolamine; AVOID β-monotherapy (ACC/AHA 2017; Vaughan JAMA 2000)
  • clonidine_or_BB_withdrawal
    history • used at CONTEXT
    Reinstitute the abruptly withdrawn agent (ACC/AHA 2017; JNC 8, James 2014)

12-phase flow (10)

  1. 1FRAME
    Differentiate emergency (end-organ damage → IV/ICU) vs urgency (no damage → oral/days) per ACC/AHA 2017
    inputs: sbp, dbp, neuro_deficit
    advance: emergency vs urgency classified
  2. 2ENTRY
    Recognize SBP >180 / DBP >120 + end-organ symptom (ACC/AHA 2017; Whelton 2018)
    inputs: age
    advance: crisis recognized
  3. 3CONTEXT
    Pregnancy (ACOG 2019), sympathomimetic exposure, abrupt drug withdrawal, comorbid CKD/CAD/HF
    inputs: pregnancy, cocaine_or_meth, clonidine_or_BB_withdrawal
    advance: context complete
  4. 4RED_FLAGS
    Aortic dissection (ACC/AHA 2022), ICH (Anderson NEJM 2023), ischemic stroke, ACS, pulmonary edema, eclampsia (ACOG 2019), scleroderma renal crisis
    inputs: neuro_deficit, chest_back_pain
    actions: aortic_dissection, ich, acute_stroke, acs_pathway, preeclampsia, scleroderma_renal_crisis
    advance: specific syndrome routed
  5. 5INITIAL_WORKUP
    BMP, troponin, ECG, CXR; CT head if neuro / CTA if dissection suspected; UA + UPCR; β-hCG if reproductive-age female (ACC/AHA 2017; ESC/ESH 2023)
    inputs: creatinine, troponin, ecg, cxr
    actions: panel.cardiac, panel.renal
    advance: syndrome-specific workup complete
  6. 6DIFFERENTIAL
    Syndrome-specific (dissection / ICH / ischemic stroke / encephalopathy / PRES / eclampsia / acute pulm edema / SRC / sympathetic crisis) per Vaughan JAMA 2000
    advance: syndrome assigned
  7. 7RISK_STRATIFICATION
    Severity by organ system; ICU triage (ACC/AHA 2017)
    inputs: lactate
    advance: severity documented
  8. 8TREATMENT
    Syndrome-specific IV per ACC/AHA 2017: dissection (esmolol → nicardipine, SBP <120 / HR <60 in 20 min); ischemic stroke permissive unless lytic; ICH SBP 130–140 (INTERACT2, Anderson NEJM 2023); eclampsia <160/110 + MgSO4 (ACOG 2019); sympathetic → phentolamine + benzo; SRC → captopril (DO NOT stop with rising Cr); general — reduce MAP ≤25% in first hour
    inputs: sbp, dbp, hr
    advance: BP at syndrome-specific target with monitoring plan
  9. 9DISPOSITION
    ICU emergency; floor or close monitoring for urgency (ACC/AHA 2017)
    advance: unit assigned
  10. 10MONITORING
    Arterial line + q5min BP for emergency; q15min for urgency; serial neuro + perfusion + Cr + troponin (ESC/ESH 2023; ACC/AHA 2017)
    inputs: sbp, creatinine
    actions: panel.renal
    advance: monitoring plan in place