What is the management for a 55-year-old female with severe hypertension (blood pressure 210/110 mmHg) presenting with dizziness?

Management of Severe Hypertension with Dizziness in a 55-Year-Old Female

The 55-year-old female with BP 210/110 mmHg and dizziness requires immediate treatment as a hypertensive urgency with careful blood pressure reduction to prevent complications. 1

Initial Assessment and Classification

• This presentation represents a hypertensive urgency - severe blood pressure elevation without evidence of acute target organ damage, but with symptoms (dizziness) 1
• Confirm blood pressure elevation with repeated measurements in both arms 1
• Evaluate for signs of hypertensive emergency (encephalopathy, stroke, heart failure, aortic dissection) through physical examination, fundoscopic exam, and basic laboratory tests 1

Immediate Management

• Goal: Reduce blood pressure by no more than 25% within the first hour, then aim for BP <160/100-110 mmHg within the next 2-6 hours 1
• Avoid excessive rapid drops in blood pressure which may precipitate renal, cerebral, or coronary ischemia 1
• Observe for at least 2 hours to evaluate BP lowering efficacy and safety 1

Medication Options

First-line medications for immediate treatment:

• Oral captopril (ACE inhibitor), labetalol (combined alpha and beta-blocker), or extended-release nifedipine 1
• Avoid short-acting nifedipine as it can cause unpredictable and excessive drops in blood pressure 1

If intravenous treatment is needed:

• Labetalol: Initial mini-bolus injection (20 mg) followed by repeated incremental doses of 20-80 mg at 10-minute intervals 2
• Nicardipine: Start at 5 mg/hr, increase by 2.5 mg/hr every 15 minutes up to maximum 15 mg/hr until desired blood pressure reduction is achieved 3

Long-term Management Strategy

First-line combination therapy:

• Combination therapy with two first-line agents is recommended for severe hypertension 4
• Preferred combinations include:
  • RAS blocker (ACE inhibitor or ARB) + calcium channel blocker 4
  • RAS blocker + thiazide/thiazide-like diuretic 4
  • Calcium channel blocker + thiazide/thiazide-like diuretic 4

For resistant hypertension (if needed):

• Add low-dose spironolactone (25-50 mg/day) to existing treatment 4
• If intolerant to spironolactone, consider eplerenone, amiloride, higher dose thiazide/thiazide-like diuretic, or loop diuretic 4
• Additional options include bisoprolol or doxazosin 4

Follow-up and Monitoring

• Schedule follow-up within 1-2 weeks to assess blood pressure control 1
• Address medication adherence issues, as many hypertensive urgencies result from non-compliance 1
• Screen for secondary causes of hypertension, especially in patients with recurrent hypertensive crises 1
• Evaluate for target organ damage with appropriate tests (echocardiogram, renal function, urinalysis) 4

Special Considerations

• If patient develops signs of hypertensive emergency (BP ≥170/110 mmHg with target organ damage), immediate hospitalization is recommended 4
• For patients with diabetes, target systolic BP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg 4
• For older patients (≥65 years), target systolic BP range of 130-139 mmHg 4

Potential Pitfalls

• Avoid excessive rapid blood pressure reduction which can lead to organ hypoperfusion 1
• Monitor for side effects of medications, particularly when using multiple agents 4
• Be cautious with labetalol infusions which can cause profound cardiovascular compromise in critically ill patients 5
• Recognize that resistant hypertension may require specialized care and consideration of secondary causes 4