What is the best course of action for a 60-year-old male with severe hypertension (blood pressure 172/112 mmHg) and no symptoms?

Management of Severe Hypertension in a 60-Year-Old Male

For a 60-year-old male with severe hypertension (172/112 mmHg) and no symptoms, start oral amlodipine 5 mg daily rather than sending to the ER, as this is consistent with current hypertension management guidelines for asymptomatic severe hypertension. 1

Assessment of Hypertension Severity

This patient presents with:

• Severe hypertension (172/112 mmHg)
• No symptoms of end-organ damage
• Age 60 years

This blood pressure reading falls into Grade 2 Hypertension (≥160/100 mmHg) according to the International Society of Hypertension guidelines 1, which requires prompt treatment but not emergency intervention in the absence of symptoms.

Treatment Decision Algorithm

1. Determine if hypertensive emergency exists:

   • No altered mental status
   • No chest pain, shortness of breath, or neurological symptoms
   • No visual changes or severe headache
   • → This is NOT a hypertensive emergency

2. Initiate appropriate therapy:

   • Asymptomatic severe hypertension → Oral medication appropriate
   • Amlodipine 5 mg daily is an appropriate first-line agent 2

Rationale for Amlodipine

Amlodipine is an excellent choice because:

• It's a dihydropyridine calcium channel blocker (DHP-CCB) that effectively reduces blood pressure 2
• It has a gradual onset of action, avoiding precipitous drops in blood pressure 2
• It has a long half-life (30-50 hours) providing 24-hour coverage with once-daily dosing 2, 3
• It's effective as monotherapy in reducing systolic blood pressure by a mean of 17.5 mmHg 4

Follow-up Recommendations

• Schedule follow-up within 1-2 weeks to assess response
• Target blood pressure reduction should aim for <140/90 mmHg initially 1
• Long-term target should be 120-129 mmHg systolic if tolerated 1
• Add lifestyle modifications (weight loss, DASH diet, sodium restriction, physical activity)

When to Consider ER Referral

Emergency department referral would be appropriate if:

• Patient had symptoms of end-organ damage (headache, visual changes, chest pain, neurological deficits)
• Blood pressure was significantly higher (e.g., >180/120 mmHg)
• Patient was unable to reliably follow up or take oral medications

Treatment Escalation if Needed

If blood pressure remains uncontrolled at follow-up:

1. Increase amlodipine to 10 mg daily
2. Consider adding a second agent (ACE inhibitor/ARB or thiazide diuretic)
3. For resistant hypertension, consider adding a third agent

Important Caveats

• Avoid rapid blood pressure reduction which can lead to organ hypoperfusion
• Monitor for common side effects of amlodipine including peripheral edema, headache, and flushing 2
• For patients aged 60 years or older, the European Society of Cardiology recommends a target systolic BP of 120-129 mmHg if tolerated 1
• If the patient develops symptoms of end-organ damage at any point, immediate referral to the emergency department is warranted 5