What is the workup and management plan for a patient with hypertensive crisis in a primary care (PC) setting?

Management of Hypertensive Crisis in Primary Care Setting

The management of hypertensive crisis in primary care should focus on identifying end-organ damage, as patients with hypertensive emergency require immediate hospitalization, while those with hypertensive urgency can be managed in the outpatient setting with gradual blood pressure reduction over 24-48 hours. 1, 2

Initial Assessment

• Determine if the patient has a hypertensive emergency (severe hypertension with evidence of acute end-organ damage) or hypertensive urgency (severe hypertension without acute end-organ damage) 1, 3
• Obtain at least two blood pressure measurements to confirm hypertensive crisis (systolic BP >180 mmHg or diastolic BP >120 mmHg) 4
• Assess for symptoms of end-organ damage:
  • Neurological: headache, altered mental status, vision changes, focal deficits 4
  • Cardiac: chest pain, shortness of breath, palpitations 4
  • Renal: oliguria, hematuria 5

Diagnostic Workup

• Essential tests for all patients with hypertensive crisis in primary care:
  • Urinalysis (dipstick) to detect proteinuria or hematuria 4
  • Serum electrolytes, BUN, and creatinine to assess renal function 4
  • Electrocardiogram to evaluate for left ventricular hypertrophy or ischemia 4
  • Blood glucose measurement 4
  • Complete blood count 4

Management Algorithm

Hypertensive Emergency (with end-organ damage)

• Immediate referral to emergency department/hospital 4
• Do not attempt to rapidly lower blood pressure in primary care setting as this may be harmful 4

Hypertensive Urgency (without end-organ damage)

• Can be managed in primary care if follow-up is assured 4
• Gradually lower blood pressure over 24-48 hours, not aiming for immediate normalization 4, 2
• Oral antihypertensive options:
  • Reinstitute or intensify previous antihypertensive regimen 6
  • If new prescription needed, consider starting with the lowest recommended dose 4
  • Avoid rapid-acting agents like immediate-release nifedipine due to risk of precipitous drops 1

Important Cautions

• Rapidly lowering blood pressure in asymptomatic patients is unnecessary and potentially harmful 4
• Up to one-third of patients with diastolic BP >95 mmHg on initial visit may normalize before follow-up 4
• Avoid indiscriminate use of immediate-release nifedipine or furosemide 6

Follow-up Plan

• Schedule follow-up within 24-72 hours to reassess blood pressure control 4
• Once stabilized, follow-up visits every 1-3 months until target blood pressure is achieved 4
• Consider referral for specialist advice for:
  • Patients under 35 years old with hypertension 4
  • Refractory hypertension (failure of two or more drugs) 4
  • Suspected secondary hypertension (hypokalaemia, proteinuria) 4
  • Hypertension with multiple cardiovascular risk factors 4

Special Considerations

• In patients with renal involvement, maintain systolic BP in the range of 130-139 mmHg after the acute phase 5
• For pregnant patients with severe pre-eclampsia, refer immediately to hospital for management with labetalol or nicardipine 4
• For patients with suspected drug-induced hypertensive crisis (cocaine, amphetamines), benzodiazepines should be administered first in the emergency setting 4

Remember that the primary care physician's most important role in hypertensive crisis is proper identification, initial assessment, and appropriate triage to emergency care when needed, rather than attempting aggressive blood pressure reduction in the office setting 4, 7.