At what blood pressure should treatment be initiated in an acute setting?

From the Guidelines

In an acute setting, treatment for hypertension should generally be initiated when systolic blood pressure exceeds 180 mmHg or diastolic blood pressure exceeds 120 mmHg, as indicated by the 2020 international society of hypertension global hypertension practice guidelines 1.

Key Considerations

• The goal of treatment is to reduce blood pressure by approximately 15-25% within the first hour, then gradually to a target blood pressure, which varies depending on the specific clinical presentation, as outlined in Table 12 of the 2020 guidelines 1.
• For patients with acute ischemic stroke and an indication for thrombolytic therapy, blood pressure should be lowered to <185 mmHg systolic and 110 mmHg diastolic before thrombolysis is given, as recommended by the esc council on hypertension position document 1.
• First-line medications for hypertensive emergencies include intravenous labetalol, nicardipine, or clevidipine, with specific medication choices tailored to the patient's condition, such as nitroprusside for aortic dissection or hydralazine for preeclampsia.

Clinical Presentations and Target Blood Pressures

• Acute ischemic stroke with systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg: reduce mean arterial pressure by 15% within 1 hour 1.
• Acute hemorrhagic stroke with systolic blood pressure >180 mmHg: target blood pressure 130-180 mmHg 1.
• Acute coronary event or acute cardiogenic pulmonary edema: target systolic blood pressure <140 mmHg 1.
• Acute aortic disease: target systolic blood pressure <120 mmHg and heart rate <60 bpm 1.

Monitoring and Assessment

• Continuously monitor the patient's blood pressure and assess for end-organ damage, such as neurological changes, chest pain, pulmonary edema, or acute kidney injury, to determine the urgency of intervention 1.

From the Research

Blood Pressure Threshold for Treatment Initiation

• The blood pressure threshold for initiating treatment in an acute setting is typically considered to be a systolic blood pressure > 180 mm Hg or a diastolic blood pressure > 120 mm Hg, which is defined as a "hypertensive crisis" 2, 3, 4, 5.
• However, it is important to note that an acute rise in blood pressure may also lead to end-organ damage before achieving this blood pressure threshold 3.
• In patients with acute end-organ damage (i.e., hypertensive emergency), immediate reduction in blood pressure is required, and treatment should be initiated promptly 2, 5.

Treatment Approach

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, and the treatment approach depends on the degree of blood pressure elevation and the presence of end-organ damage 2, 3, 4, 5.
• In patients with hypertensive emergencies, treatment with a titratable short-acting intravenous antihypertensive agent is recommended, while those with hypertensive urgencies can be treated with oral antihypertensive agents 2, 5.
• The choice of antihypertensive medication depends on the clinical presentation of the patient and the threat of end-organ damage resulting from blood pressure elevation 6.

Specific Blood Pressure Targets

• In patients with acute aortic dissection, the goal is to maintain a systolic reading of less than 120 mm Hg, and intravenous esmolol should be administered within 5 to 10 minutes to lower blood pressure quickly 4.
• In general, the aim is to lower blood pressure by about 25% within one to two hours in patients with hypertensive emergencies, while in those with hypertensive urgencies, blood pressure should be lowered within 24 to 48 hours 5.