How to manage a patient with severe hypertension (blood pressure 212/108) in the emergency department?

Management of Severe Hypertension (212/108) in the Emergency Department

Rapidly lowering blood pressure in asymptomatic patients in the emergency department is unnecessary and may be harmful. Instead, focus on evaluating for end-organ damage and providing appropriate follow-up for patients without evidence of acute target organ injury. 1

Initial Assessment

1. Evaluate for hypertensive emergency vs. urgency:

   • Hypertensive emergency: BP >180/120 mmHg WITH evidence of acute end-organ damage
   • Hypertensive urgency: BP >180/120 mmHg WITHOUT evidence of acute end-organ damage

2. Assessment for end-organ damage:

   • Physical examination including fundoscopy
   • Laboratory tests: serum creatinine, eGFR, urine albumin-to-creatinine ratio
   • 12-lead ECG
   • Additional tests if symptoms present: echocardiography, neuroimaging, chest imaging 2

Management Algorithm

If Hypertensive Emergency (with end-organ damage):

1. Immediate hospitalization (preferably ICU)
2. Intravenous antihypertensive therapy with continuous monitoring
3. Target: Reduce mean arterial pressure by 20-25% within the first hour, not to normal values 2
4. Medication options:
   • Nicardipine: Start at 5 mg/h IV, increase by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 2, 3
   • Clevidipine: Start at 1-2 mg/h IV, double dose every 90 seconds initially
   • Labetalol: 0.3-1.0 mg/kg IV (maximum 20 mg), repeat every 10 minutes or continuous infusion
   • Esmolol: 0.5-1 mg/kg IV bolus, then 50-300 μg/kg/min continuous infusion 2

If Hypertensive Urgency (without end-organ damage):

1. Outpatient management is appropriate when follow-up is available
2. Do not rapidly lower blood pressure - gradual reduction over 24-48 hours is preferred 1, 4
3. Oral medication options:
   • Combination therapy with RAS blocker + calcium channel blocker
   • Combination therapy with RAS blocker + thiazide diuretic 2
   • For Black patients: Start with diuretic or calcium channel blocker 2
4. Arrange prompt follow-up within 1-2 weeks 2

Important Considerations

• Up to one-third of patients with elevated diastolic blood pressure >95 mmHg on initial ED visit normalize before arranged follow-up 1
• Excessive BP reduction can lead to organ hypoperfusion and worsen outcomes 2, 5
• The severity of hypertensive crisis is determined not just by absolute BP level but by the magnitude of acute increase 5
• In patients with chronic hypertension, the autoregulation curve is altered, making rapid normalization of BP potentially dangerous 5

Common Pitfalls to Avoid

1. Overly aggressive BP reduction in asymptomatic patients - this may cause harm 1, 2
2. Failure to assess for end-organ damage - this determines treatment urgency 2
3. Not screening for underlying causes of severe hypertension 2
4. Using inappropriate medications like hydralazine, immediate-release nifedipine, or nitroglycerin 6
5. Using sodium nitroprusside without caution due to its toxicity profile 6
6. Not arranging appropriate follow-up for patients with hypertensive urgency 1, 2

Follow-up Recommendations

• For patients with hypertensive urgency discharged from the ED:
  • Schedule follow-up within 1-2 weeks
  • For suboptimally treated hypertension or suspected non-adherence, monthly visits in a specialized setting until target BP is reached 2
• When transitioning from IV to oral therapy, administer first oral dose 1 hour before discontinuing IV infusion 2, 3

Remember that the primary goal in managing severe hypertension is preventing morbidity and mortality, which is best achieved by appropriate triage based on the presence or absence of end-organ damage rather than by focusing solely on blood pressure numbers.