What to do for a patient with severely elevated blood pressure (hypertension) of 190/90?

Management of Severely Elevated Blood Pressure (190/90 mmHg)

A blood pressure of 190/90 mmHg represents Grade 2 Hypertension requiring immediate drug treatment along with lifestyle interventions to reduce the significant cardiovascular risk. Start antihypertensive medication immediately while simultaneously implementing lifestyle modifications to reduce morbidity and mortality. 1

Immediate Assessment and Management

• Confirm the elevated reading by taking at least two more measurements using a validated device with appropriate cuff size 1
• Evaluate for signs of end-organ damage (headache, visual changes, chest pain, shortness of breath, neurological symptoms) to differentiate between hypertensive urgency and emergency 2
• If no signs of acute end-organ damage are present (hypertensive urgency), oral medications can be initiated 2
• If signs of end-organ damage are present (hypertensive emergency), immediate hospitalization and IV antihypertensive therapy are required 2, 3

Pharmacological Treatment

For patients with BP 190/90 mmHg without end-organ damage (hypertensive urgency):

• Start immediate drug treatment as this is Grade 2 Hypertension (≥160/100 mmHg) 1
• Treatment algorithm based on patient demographics:

For Non-Black Patients:

1. Start with low-dose ACEI/ARB (e.g., lisinopril) 1, 4
2. Increase to full dose if needed 1
3. Add thiazide/thiazide-like diuretic if target not achieved 1
4. Add calcium channel blocker (e.g., amlodipine) if needed 1, 5

For Black Patients:

1. Start with low-dose ARB plus DHP-CCB (e.g., amlodipine) or DHP-CCB plus thiazide-like diuretic 1, 5
2. Increase to full dose if needed 1
3. Add diuretic or ACEI/ARB if target not achieved 1

Blood Pressure Targets

• Initial goal: Reduce BP by at least 20/10 mmHg 1
• Target BP: <130/80 mmHg for most adults 1, 6
• For elderly patients, individualize target based on frailty 1
• Aim to achieve target BP within 3 months 1

Lifestyle Modifications (Implement Simultaneously)

• Dietary modifications: Low sodium (<2g/day), high potassium intake, DASH diet pattern 6
• Weight loss for overweight/obese patients 6
• Regular physical activity: 150 minutes of moderate-intensity exercise per week 6
• Limit alcohol consumption or eliminate entirely 6
• Smoking cessation 7

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks to assess response to therapy 1
• Monitor for medication adherence and side effects 1
• Consider home BP monitoring to track progress and improve adherence 1
• If BP remains uncontrolled despite multiple medications, refer to a specialist with expertise in hypertension management 1

Important Considerations and Pitfalls

• Avoid rapid reduction of BP to normal levels in patients with chronic hypertension, as this can lead to hypoperfusion due to altered autoregulation 3
• For hypertensive urgency, reduce BP gradually over 24-48 hours rather than immediately 3
• Avoid medications like immediate-release nifedipine that can cause unpredictable rapid drops in BP 2
• Consider global cardiovascular risk reduction by addressing other risk factors such as hypercholesterolemia 7
• Assess for secondary causes of hypertension, particularly with severe or resistant hypertension 1

Remember that lowering blood pressure significantly reduces the risk of cardiovascular events, with an SBP reduction of 10 mmHg decreasing CVD risk by approximately 20-30% 6.