Workup for Severe Hypertension in a COVID-19 Patient
For a patient presenting with severe hypertension (160/117) and COVID-19, the initial workup should focus on assessing end-organ damage while maintaining appropriate COVID-19 precautions and continuing any existing antihypertensive medications, especially RAAS inhibitors.
Initial Assessment
Vital Signs and Physical Examination
- Complete vital sign assessment (temperature, heart rate, respiratory rate, oxygen saturation)
- Focused cardiovascular and pulmonary examination
- Neurological assessment for signs of hypertensive emergency
- Check for peripheral edema
Laboratory Tests
- Complete blood count
- Comprehensive metabolic panel (kidney and liver function)
- C-reactive protein and ferritin (COVID-19 severity markers)
- Urinalysis (to assess for proteinuria/hematuria)
- Thyroid function tests
- B-type natriuretic peptide (if heart failure suspected)
Cardiac Assessment
- 12-lead ECG to assess for left ventricular hypertrophy, ischemia, or arrhythmias
- Consider point-of-care cardiac ultrasound if available and clinically indicated
COVID-19 Specific Assessment
- Assess oxygen requirements and respiratory status
- Consider lying and standing blood pressure measurements (3-minute active stand test) to evaluate for postural hypotension 1
Imaging
- Chest X-ray to evaluate for COVID-19 pneumonia and assess cardiac silhouette
- Consider chest CT if severe respiratory symptoms present
Risk Stratification
Determine if Hypertensive Emergency is Present
- Check for:
- Acute target organ damage (brain, heart, kidneys)
- Visual disturbances
- Chest pain
- Shortness of breath beyond expected for COVID-19
- Altered mental status
COVID-19 Severity Assessment
- Evaluate for signs of severe COVID-19 including hypoxemia or oxygen desaturation on exercise 1
- Assess for multisystem inflammatory syndrome
Management Considerations
Antihypertensive Therapy
- Continue existing RAAS inhibitors (ACE inhibitors or ARBs) as evidence shows they are safe and potentially protective in COVID-19 patients 1
- Do not discontinue antihypertensive medications unless clinically necessary 1
- For patients not previously on antihypertensives, initiate treatment according to standard hypertension guidelines
COVID-19 Treatment
- Consider appropriate COVID-19 therapies based on severity and risk factors
- For high-risk patients, consider antiviral therapy (e.g., remdesivir) if within appropriate timeframe 2
Special Considerations
Thromboprophylaxis
- For hospitalized patients, use prophylactic-intensity anticoagulation 1
- For non-ICU hospitalized patients with hypertension, continue antiplatelet therapy if previously prescribed and add prophylactic-dose anticoagulation 1
Monitoring
- Regular blood pressure monitoring
- Continuous assessment of COVID-19 symptoms
- Monitor for drug interactions between COVID-19 treatments and antihypertensive medications 1
Pitfalls to Avoid
- Do not assume elevated blood pressure is solely due to COVID-19 anxiety or stress
- Avoid discontinuing RAAS inhibitors based on theoretical concerns about COVID-19 severity
- Remember that hypertension alone has not been established as an independent risk factor for COVID-19 severity after accounting for age and other comorbidities 1
- Be aware that the pandemic may have disrupted routine hypertension care, potentially leading to uncontrolled blood pressure 1
By following this structured approach, you can appropriately evaluate and manage a patient presenting with severe hypertension in the context of COVID-19 infection, addressing both conditions while minimizing risk of complications.