What is the best course of action for an 85-year-old male with atrial fibrillation, hypertension, and osteomyelitis, presenting with severe hypertension and a recently normalized heart rate, after missing anti-hypertensive and anticoagulant medications?

From the Guidelines

This patient requires immediate management of severe hypertension, and I recommend administering IV labetalol 10-20 mg over 2 minutes, which can be repeated every 10 minutes (maximum 300 mg) until blood pressure decreases to a safer range, aiming for a gradual reduction to avoid organ hypoperfusion. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, the recommended first-line treatments for hypertension include ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics. However, given the patient's age (85 years) and severe hypertension, a more cautious approach may be necessary.

The patient's history of atrial fibrillation and current severe hypertension increases his risk of stroke, myocardial infarction, or acute kidney injury. For his atrial fibrillation, assessing his CHA₂DS₂-VASc score to determine appropriate anticoagulation therapy is crucial, likely with apixaban 5 mg twice daily or warfarin with target INR 2-3, as recommended by the American Heart Association/American Stroke Association Stroke Council 1.

Key considerations in managing this patient's hypertension include:

• Monitoring blood pressure every 15 minutes initially, then hourly until stable
• Restarting his home antihypertensive medications and blood thinners after confirming the specific agents and doses
• Continuous cardiac monitoring given his history of atrial fibrillation and recent medication changes
• Assessing his CHA₂DS₂-VASc score to determine appropriate anticoagulation therapy

Given the patient's age and comorbidities, it is essential to prioritize a cautious and gradual approach to managing his severe hypertension, while also addressing his atrial fibrillation and anticoagulation needs. The 2024 ESC guidelines 1 provide a framework for managing hypertension, and the American Heart Association/American Stroke Association Stroke Council recommendations 1 guide anticoagulation therapy for atrial fibrillation.

From the FDA Drug Label

The dosage and administration of warfarin sodium tablets must be individualized for each patient according to the particular patient’s PT/INR response to the drug. For patients with non-valvular atrial fibrillation (AF), the American College of Chest Physicians’ (7th ACCP) recommendation is that an INR of 2.0-3.0 be used for warfarin therapy in appropriate AF patients.

The patient has a history of Afib and was not taking his blood thinners. Warfarin should be restarted, but the dosage must be individualized based on the patient's PT/INR response. The target INR for Afib patients is 2.0-3.0. However, the patient's current INR is unknown, and no conclusion can be drawn about the exact dosage without this information.

• The patient's warfarin therapy should be restarted under close monitoring of PT/INR.
• Caution should be exercised when restarting warfarin in this patient, as he has been off his anticoagulation therapy and may be at increased risk of thromboembolic events.
• The patient's PT/INR should be closely monitored to adjust the warfarin dosage accordingly 2.

From the Research

Patient Assessment

• The patient is an 85-year-old male with a past medical history (PMH) of atrial fibrillation (Afib), hypertension (HTN), and is being admitted to the hospital floor for osteomyelitis.
• The patient was not given any of his anti-hypertension medications at the other hospital and did not take any of his blood thinners.
• The patient's current blood pressure is 213/117, heart rate has been in the low 40's but is now in the normal 80's, oxygen saturation (SpO2) is 98%, and respirations are normal.
• The patient is not symptomatic.

Hypertension Management

• According to the study by 3, severely elevated blood pressure without signs or symptoms of end-organ damage (severe asymptomatic hypertension) does not require immediate workup or treatment.
• The study by 4 found that only around two-thirds of patients with severely elevated blood pressure were given immediate blood pressure lowering medication, and most patients were managed in the general practitioner's office unless a hypertensive emergency was present.
• The study by 5 suggests that clevidipine, a dihydropyridine calcium channel antagonist, is effective in reducing blood pressure in adults with acute severe hypertension.
• The study by 6 compared the efficacy and safety of nicardipine and clevidipine for blood pressure control in hypertensive crisis, and found that nicardipine achieved a systolic blood pressure goal of <160 mm Hg at 2-6 hours significantly more often than the clevidipine group.

Treatment Considerations

• The patient's severely elevated blood pressure may require urgent attention, but the lack of symptoms suggests that it may not be a true medical emergency 7.
• The patient's history of Afib and HTN, as well as the current elevated blood pressure, should be taken into consideration when determining the best course of treatment.
• The use of intravenous medications such as clevidipine or nicardipine may be considered to rapidly lower the patient's blood pressure, but the choice of medication and the rate of titration should be carefully considered to avoid rebound hypertension 6.