From the Guidelines
A blood pressure of 195/105 mmHg with elevated creatinine indicating impaired renal function is considered a hypertensive emergency, not just an urgency, in a 77-year-old patient. This situation requires immediate medical attention in an emergency department or intensive care setting. The patient needs controlled blood pressure reduction using intravenous medications like labetalol, nicardipine, or clevidipine, as suggested by the management of hypertensive emergencies 1. The goal is to lower blood pressure by no more than 25% within the first hour, then to 160/100 mmHg within the next 2-6 hours, and gradually normalize over 24-48 hours. Rapid, uncontrolled reduction could compromise organ perfusion, especially to the brain and kidneys.
Key Considerations
- The elevated creatinine suggests the hypertension is already causing end-organ damage to the kidneys, which defines this as an emergency rather than an urgency.
- The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends careful monitoring for orthostatic hypotension during treatment, especially in older adults 1.
- Intensive blood pressure control may increase the risk of acute kidney injury, but this risk is similar to that seen in younger adults 1.
Management Approach
- After stabilization, the patient will need comprehensive evaluation of kidney function, assessment for other end-organ damage, and establishment of a long-term antihypertensive regimen, likely including multiple medications targeting different blood pressure control mechanisms.
- The choice of antihypertensive therapy should be individualized, considering the patient's comorbidities, potential drug interactions, and the presence of other cardiovascular risk factors.
- Close monitoring of blood pressure, kidney function, and overall clinical status is crucial during the treatment period to adjust the therapeutic approach as needed.
From the Research
Definition of Hypertensive Urgency
- A blood pressure of 195/105 mmHg is considered severely elevated, but according to the study 2, hypertensive urgencies are defined as a severe elevation in BP, higher than 180/120 mmHg, associated or not with the evidence of new or worsening organ damage.
- The patient's blood pressure is above the threshold for hypertensive urgency, but the presence of elevated creatinine (1.9) indicating impaired renal function is also a critical factor to consider.
Impaired Renal Function and Hypertension
- The study 3 highlights the complexity of managing blood pressure in patients with end-stage renal disease (ESRD), emphasizing the importance of controlling extracellular volume and using antihypertensive medications judiciously.
- Elevated creatinine levels are associated with higher systolic and diastolic blood pressures, presence of hypertension, and older age, as noted in the study 4.
- The study 5 suggests that certain antihypertensive medications, such as ACE inhibitors, may have beneficial effects on renal function, but can also cause acute deterioration in renal function, particularly in patients with bilateral renal artery stenosis or stenosis of a solitary functioning kidney.
Management of Hypertensive Urgency with Impaired Renal Function
- The study 2 recommends a gradual lowering of BP over 24-48 hours with an oral medication for hypertensive urgencies, avoiding aggressive BP lowering.
- In patients with impaired renal function, careful consideration of the underlying causes of the crisis, patient demographics, cardiovascular risk, and comorbidities is necessary when selecting antihypertensive medications, as noted in the study 2.
- The study 6 suggests that renovascular hypertension should be considered in patients with resistant hypertension or those with increasing plasma creatinine levels on ACE inhibitor therapy, and that medical management, including intensive correction of cardiovascular risk factors, may be appropriate.