What is the management for a patient with severe hypertension (blood pressure 208/106)?

Management of Severe Hypertension (BP 208/106)

A patient with blood pressure of 208/106 requires immediate assessment for hypertensive emergency and should receive controlled blood pressure reduction with intravenous labetalol or nicardipine as first-line treatment if evidence of acute target organ damage is present.

Initial Assessment

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

• Hypertensive Emergency: Severe BP elevation (>180/120 mmHg) WITH evidence of new/worsening target organ damage
• Hypertensive Urgency: Severe BP elevation WITHOUT acute target organ damage

Signs of Target Organ Damage to Evaluate:

• Neurological: Altered mental status, seizures, focal deficits, severe headache (hypertensive encephalopathy)
• Cardiovascular: Chest pain, pulmonary edema, new ECG changes
• Renal: Acute kidney injury, hematuria, proteinuria
• Ophthalmologic: Papilledema, retinal hemorrhages, exudates
• Vascular: Signs of aortic dissection (tearing chest pain radiating to back)

Management Algorithm

If Hypertensive Emergency:

1. Immediate Action:

   • Admit to intensive care unit for continuous BP monitoring 1
   • Administer parenteral antihypertensive therapy

2. BP Reduction Targets:

   • For most conditions: Reduce BP by no more than 25% within first hour
   • Then reduce to 160/100 mmHg within next 2-6 hours
   • Gradually normalize over 24-48 hours 1, 2

3. First-line IV Medications:

   • Labetalol: Initial 0.3-1.0 mg/kg dose (maximum 20 mg) slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion 1, 2
   • Nicardipine: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1, 3

If Hypertensive Urgency:

1. Action:

   • Reinstitute or intensify oral antihypertensive therapy 1
   • Observe for 2-3 hours to ensure BP begins to decrease 1

2. Oral Medication Options:

   • Captopril, labetalol, or long-acting nifedipine (avoid short-acting nifedipine) 1, 2
   • Target gradual BP reduction over 24-48 hours 4

3. Follow-up:

   • Arrange close follow-up within 1 week 2

Special Considerations

For Specific Conditions:

• Acute Stroke:

  • For ischemic stroke: Generally withhold BP-lowering unless BP >220/120 mmHg or thrombolysis planned 1
  • For hemorrhagic stroke with SBP ≥220 mmHg: Consider careful reduction to <180 mmHg 1

• Aortic Dissection:

  • Reduce SBP to <120 mmHg within first hour 1

Medication Selection Caveats:

• Avoid short-acting nifedipine due to risk of precipitous BP drops 2
• Avoid hydralazine in most emergency situations due to unpredictable response 5
• Use sodium nitroprusside with caution due to toxicity concerns 5

Long-term Management

After acute management:

1. Transition to oral therapy once BP is stabilized
2. Investigate causes of severe hypertension, including screening for secondary hypertension
3. Maintenance therapy should include combination of first-line agents:
   • RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide-like diuretic 1
   • Consider single-pill combinations to improve adherence 1
4. Target BP should be 120-129 mmHg systolic for most adults 1

Pitfalls to Avoid

• Excessive rapid BP reduction can cause organ hypoperfusion and ischemia
• Failing to distinguish between urgency and emergency can lead to inappropriate treatment
• Neglecting to screen for secondary causes of hypertension, especially in previously untreated patients
• Discharging patients without adequate follow-up plans

The management of severe hypertension requires careful assessment, appropriate medication selection, and controlled BP reduction to prevent complications while effectively treating this potentially life-threatening condition.