How should I manage a patient with severe hypertension?

Management of Severe Hypertension (BP 194/113)

A patient with BP 194/113 should be assessed for signs of hypertensive emergency with target organ damage, and if none are present, treated as a hypertensive urgency with controlled BP reduction over 24-48 hours using oral medications rather than rapid IV therapy. 1

Initial Assessment

First, determine if this is a hypertensive emergency or urgency:

• Hypertensive Emergency: BP >180/120 mmHg WITH evidence of acute target organ damage

  • Look for: altered mental status, chest pain, shortness of breath, visual changes, severe headache, focal neurological deficits, pulmonary edema, acute kidney injury
  • Requires immediate BP reduction in intensive care setting

• Hypertensive Urgency: BP >180/120 mmHg WITHOUT evidence of acute target organ damage

  • May have non-specific symptoms like headache, malaise, anxiety
  • Requires controlled BP reduction over 24-48 hours

Treatment Algorithm

If Hypertensive Emergency:

1. Admit to ICU for continuous BP monitoring and parenteral medication 1
2. Initial goal: Reduce mean arterial pressure by 20-25% within minutes to 1 hour 1
3. First-line IV medications based on specific organ damage: 1
   • General emergency: Labetalol IV (first choice)
   • Pulmonary edema: Nitroprusside or nitroglycerin with loop diuretic
   • Coronary event: Nitroglycerin
   • Aortic dissection: Esmolol + nitroprusside/nitroglycerin (target SBP <120 mmHg)
   • Stroke (ischemic): Only treat if BP >220/120 mmHg, target 15% reduction
   • Stroke (hemorrhagic): Target SBP 130-180 mmHg with labetalol

If Hypertensive Urgency (most likely scenario with BP 194/113):

1. Oral medication with observation for 2+ hours 1
2. Target: Gradual BP reduction over 24-48 hours 1
3. First-line oral options:
   • Captopril (ACE inhibitor)
   • Labetalol (combined alpha/beta blocker)
   • Long-acting nifedipine (calcium channel blocker)

Important Cautions

• AVOID short-acting nifedipine - can cause precipitous BP drops leading to cerebral, renal, or coronary ischemia 1
• AVOID excessive BP reduction - patients with chronic hypertension have altered autoregulation and rapid normalization can cause hypoperfusion 2
• AVOID discharging patients without ensuring adequate follow-up within 24-48 hours 3

Follow-up Plan

• If treating as outpatient, ensure follow-up within 24-48 hours
• Evaluate for causes of uncontrolled hypertension:
  • Medication non-adherence
  • Inadequate therapy
  • Secondary hypertension
• Adjust long-term antihypertensive regimen as needed

Special Considerations

• For patients with chronic hypertension, target no more than 25% reduction in first 24 hours
• If patient has neurological symptoms, consider stroke protocol and avoid aggressive BP lowering unless specifically indicated
• In elderly patients or those with atherosclerosis, more gradual BP reduction is preferred to avoid hypoperfusion

Remember that the primary goal is to prevent morbidity and mortality by safely reducing BP while avoiding complications from overly aggressive treatment.