How to manage a patient with severe hypertension?

Management of Severe Hypertension (BP 220/120 mmHg)

For a patient with BP 220/120 mmHg, immediate treatment with continuous intravenous antihypertensive medication and close blood pressure monitoring is recommended to safely lower the blood pressure.

Initial Assessment and Classification

• Determine if this is a hypertensive emergency (with acute target organ damage) or hypertensive urgency (without acute target organ damage):
  • Check for signs of acute target organ damage:
    • Neurological: Altered mental status, seizures, focal deficits (stroke, encephalopathy)
    • Cardiovascular: Chest pain, pulmonary edema, aortic dissection
    • Renal: Acute kidney injury, hematuria
    • Ophthalmologic: Papilledema, retinal hemorrhages, exudates

Management Algorithm

If Hypertensive Emergency (with acute target organ damage):

1. Immediate hospitalization in ICU setting

2. Medication selection based on specific organ involvement:

   • Intracerebral hemorrhage:

     • With SBP >220 mmHg: Use continuous IV infusion 1
     • Avoid immediate lowering of SBP to <140 mmHg as this can be harmful 1
     • Avoid acute BP reduction >70 mmHg from initial levels within 1 hour 1

   • Ischemic stroke:

     • Target 15% MAP reduction if BP >220/120 mmHg
     • Use labetalol as first-line treatment 2

   • Acute coronary event:

     • Target SBP <140 mmHg
     • Use nitroglycerin as first-line treatment 2

   • Acute cardiogenic pulmonary edema:

     • Use nitroprusside or nitroglycerin with loop diuretic 2
     • For pulmonary edema in pre-eclampsia, IV nitroglycerin is recommended 1

   • Acute aortic dissection:

     • Target SBP <120 mmHg and HR <60 bpm
     • Use esmolol and nitroprusside/nitroglycerin 2

3. First-line IV medications:

   • Labetalol
   • Nicardipine: Start at 5 mg/hr, increase by 2.5 mg/hr every 15 minutes up to 15 mg/hr 3
   • Avoid short-acting nifedipine due to risk of precipitous BP decline 2

4. Blood pressure reduction targets:

   • Reduce BP by no more than 25% within the first hour 2
   • Then aim for 160/100 mmHg within the next 2-6 hours 2
   • Cautiously reduce to normal during the following 24-48 hours 2

If Hypertensive Urgency (without acute target organ damage):

1. Treatment setting:

   • Can be managed in outpatient setting if reliable follow-up is assured
   • Otherwise, consider extended observation (4-6 hours) in emergency setting 2

2. Medication approach:

   • Oral antihypertensives are usually sufficient 4
   • Target BP reduction over 24-48 hours, not minutes 4, 5
   • First-line combination: RAS blocker plus a CCB or thiazide-like diuretic 1

3. Follow-up:

   • Schedule follow-up within 24 hours 2
   • Continue monthly follow-up until target BP is reached 2

Monitoring During Treatment

• Monitor vital signs every 30 minutes during the first 2 hours 2
• Watch for signs of organ hypoperfusion (renal, cerebral, or coronary ischemia) 2
• If hypotension or tachycardia develops, discontinue infusion temporarily 3
• When BP and heart rate stabilize, restart infusion at lower dose (3-5 mg/hr) 3
• Change peripheral IV infusion site every 12 hours 3

Special Considerations

• Renal impairment: Monitor closely when titrating antihypertensives 3
• Heart failure: Monitor closely for worsening symptoms 3
• Pregnancy-related hypertensive crisis: Use IV labetalol or nicardipine with magnesium 1
• Bradycardia with severe hypertension: Consider increased intracranial pressure 2

Common Pitfalls to Avoid

• Excessive BP reduction: Can lead to organ hypoperfusion and ischemia
• Using short-acting nifedipine: Risk of uncontrolled BP drop 2
• Inadequate monitoring: Patients require close observation during initial treatment
• Failure to identify secondary causes: Consider screening for obstructive sleep apnea, renal artery stenosis, and other secondary causes of resistant hypertension 1

By following this structured approach based on the latest guidelines, severe hypertension can be managed effectively while minimizing the risk of complications from either the hypertension itself or overly aggressive treatment.