What is the management for a patient with severe hypertension (blood pressure >180/100)?

Management of Severe Hypertension (BP >180/100)

Severe hypertension (BP >180/100) requires immediate assessment for target organ damage to determine if it's a hypertensive emergency requiring ICU admission or a hypertensive urgency that can be managed with oral medications and close follow-up.

Classification and Initial Assessment

• Hypertensive emergency is defined as severe BP elevation (>180/120 mmHg) with evidence of new or worsening target organ damage 1
• Hypertensive urgency is severe BP elevation without progressive target organ damage 1
• Assess for signs of target organ damage: hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, or eclampsia 1, 2

Management of Hypertensive Emergency

General Approach

• Admit to ICU for continuous BP monitoring and parenteral administration of appropriate antihypertensive agents 1
• The 1-year mortality rate for untreated hypertensive emergencies exceeds 79% 1

BP Reduction Goals

• For patients with compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma crisis):

  • Reduce SBP to <140 mmHg during the first hour 1
  • For aortic dissection, further reduce to <120 mmHg 1

• For patients without compelling conditions:

  • Reduce SBP by no more than 25% within the first hour 1
  • Then, if stable, reduce to 160/100 mmHg within the next 2-6 hours 1
  • Gradually reduce to normal over the following 24-48 hours 1

Recommended IV Medications

• First-line options:

  • Labetalol: Initial 0.3-1.0 mg/kg dose (maximum 20 mg) slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion 1, 3
  • Nicardipine: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1
  • Clevidipine: Initial 1-2 mg/h, doubling every 90 seconds until BP approaches target 1, 4

• Other options based on specific conditions:

  • Sodium nitroprusside: For most hypertensive emergencies, but use with caution due to cyanide toxicity risk 1
  • Nitroglycerin: Preferred for coronary ischemia 1
  • Esmolol: Useful when rapid heart rate control is needed 1
  • Fenoldopam: May be beneficial in patients with renal impairment 1

Management of Hypertensive Urgency

• Reinstitute or intensify oral antihypertensive therapy 1
• Arrange close follow-up 1
• Avoid rapid BP reduction with short-acting agents like immediate-release nifedipine 1
• For BP 160-179/100-109 mmHg, confirm as soon as possible (within 1 month) preferably with home or ambulatory BP measurements 1

Special Considerations

• Caution: Excessive falls in BP may precipitate renal, cerebral, or coronary ischemia 1
• Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals due to altered autoregulation 1, 5
• For patients with ischemic stroke, there is limited evidence supporting immediate antihypertensive treatment 1
• For BP ≥180/110 mmHg, fundoscopy is recommended to assess for hypertensive retinopathy 1

Follow-up

• After initial stabilization of hypertensive emergency, transition to oral antihypertensive therapy 4, 6
• Typically use combination therapy with a renin-angiotensin system inhibitor, thiazide diuretic, and/or calcium channel blocker 6
• Emphasize medication adherence and schedule close follow-up until goal BP is achieved 6

Common Pitfalls to Avoid

• Do not use short-acting nifedipine in the initial treatment of hypertensive emergencies or urgencies 1
• Do not reduce BP too rapidly or to normal levels immediately in patients with chronic hypertension 1, 5
• Do not discharge patients with hypertensive emergency before adequate BP control and transition to oral therapy 1
• Do not overlook potential secondary causes of severe hypertension, especially in younger patients or those with resistant hypertension 1