How to manage a patient with severe hypertension?

Management of Severe Hypertension (BP 200/110)

For a patient with severely elevated blood pressure of 200/110 mmHg, immediate treatment with intravenous antihypertensive medication (preferably labetalol or nicardipine) is recommended if there is evidence of target organ damage, constituting a hypertensive emergency. 1

Initial Assessment

• Determine if this is a hypertensive emergency (with target organ damage) or hypertensive urgency (without target organ damage):
  • Check for symptoms of acute target organ injury: headache, visual disturbances, chest pain, shortness of breath, neurological deficits
  • Evaluate for signs of end-organ damage: altered mental status, retinal hemorrhages/exudates, pulmonary edema, new cardiac murmurs
  • Order relevant tests: ECG, basic metabolic panel, urinalysis, chest X-ray if indicated

Management Algorithm

If Hypertensive Emergency (with target organ damage):

1. Immediate hospitalization and IV antihypertensive therapy

   • First-line IV medications: Labetalol or Nicardipine 1
   • Nicardipine: Start at 5 mg/hr, increase by 2.5 mg/hr every 15 minutes to maximum of 15 mg/hr 2
   • Labetalol: 10 mg IV over 1-2 min, may repeat or double every 10-20 min to maximum 300 mg 3

2. Blood pressure reduction targets:

   • Reduce BP by no more than 25% within first hour
   • Then aim for 160/100 mmHg within next 2-6 hours
   • Gradually reduce to normal over 24-48 hours 1

3. Medication selection based on specific organ involvement:

   • Cerebral involvement: Labetalol preferred
   • Cardiac involvement: Nitroglycerin
   • Aortic dissection: Esmolol plus nitroprusside or nitroglycerin
   • Pulmonary edema: Nitroprusside or nitroglycerin with loop diuretic 1

If Hypertensive Urgency (no target organ damage):

1. Consider outpatient management if reliable follow-up is assured

   • Oral antihypertensive therapy with close monitoring
   • First-line combination: RAS blocker (ACE inhibitor or ARB) plus calcium channel blocker or thiazide-like diuretic 1

2. Extended observation (4-6 hours) if uncertain about follow-up

   • Monitor vital signs every 30 minutes during first 2 hours
   • Ensure BP is trending downward before discharge

3. Follow-up:

   • Schedule follow-up within 24 hours
   • Continue with monthly follow-up until target BP is reached 1

Important Considerations

• Avoid excessive BP reduction which can lead to organ hypoperfusion (renal, cerebral, or coronary ischemia) 1
• Avoid sublingual nifedipine due to risk of precipitous BP decline 3
• Monitor for signs of organ hypoperfusion during treatment
• Change IV infusion site every 12 hours if administered via peripheral vein 2
• Patients with hypertensive emergency remain at increased risk of cardiovascular and renal disease compared to hypertensive patients without emergency 3

Long-term Management

• Transition to oral antihypertensive therapy
• Target BP generally <140/90 mmHg (or <130/80 mmHg for special populations with diabetes, renal dysfunction, or proteinuria) 1
• Address modifiable risk factors and secondary causes of hypertension
• Ensure medication adherence and regular follow-up

This approach prioritizes immediate recognition of hypertensive emergency versus urgency, appropriate medication selection, careful BP reduction targets, and proper follow-up to reduce morbidity and mortality associated with severe hypertension.