What is the treatment for a systolic blood pressure (BP) of 220 mmHg, indicating hypertensive emergency?

Management of Systolic Blood Pressure of 220 mmHg (Hypertensive Emergency)

A systolic blood pressure of 220 mmHg requires immediate assessment for end-organ damage and prompt treatment with parenteral antihypertensive medications, with the specific drug choice and blood pressure reduction target determined by the type of organ damage present. 1, 2

Initial Assessment and Classification

• A systolic BP of 220 mmHg meets criteria for potential hypertensive emergency, commonly defined as severe BP elevation (>180/120 mmHg) with evidence of acute target organ damage 1, 2
• Immediate diagnostic workup is essential to determine if end-organ damage is present, which differentiates a hypertensive emergency from urgency 1
• Target organs that should be evaluated include the retina, brain, heart, large arteries, and kidneys 1

Diagnostic Evaluation

• Medical history should focus on: preexisting hypertension, onset and duration of symptoms, potential causes (medication nonadherence, lifestyle changes, use of BP-elevating drugs) 1
• Physical examination should include thorough cardiovascular and neurologic assessment 1
• Laboratory tests should include: hemoglobin, platelets, creatinine, electrolytes, LDH, haptoglobin, urinalysis 1
• Additional examinations: fundoscopy (to detect retinopathy), ECG (to assess cardiac involvement) 1
• Further investigations based on clinical presentation may include: troponins, chest x-ray, echocardiogram, brain imaging, CT-angiography 1

Treatment Approach for Hypertensive Emergency

• If end-organ damage is present, immediate admission to intensive care unit for continuous monitoring and parenteral antihypertensive therapy is required 2
• The goal is controlled BP reduction to prevent further organ damage while avoiding hypotension 1
• Initial BP reduction should be no more than 25% of mean arterial pressure within the first hour 2
• Further reduction to 160/100-110 mmHg should occur over the next 2-6 hours, with gradual normalization over 24-48 hours 2

First-Line Intravenous Medications

• Labetalol: 20-80 mg IV bolus every 10 minutes or 0.4-1.0 mg/h IV infusion; preferred in hypertensive encephalopathy as it preserves cerebral blood flow 1, 2
• Nicardipine: Start at 5 mg/h, increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h; effective for dose-dependent decreases in blood pressure 2, 3
• Nitroprusside: Rapid onset and offset of action; however, use with caution due to toxicity concerns 1, 4

Specific Treatment Based on Clinical Presentation

• Malignant hypertension: Reduce mean arterial pressure by 20-25% over several hours 1
• Hypertensive encephalopathy: Immediate reduction of mean arterial pressure by 20-25% 1
• Acute ischemic stroke with BP >220/120 mmHg: Reduce mean arterial pressure by 15% within 1 hour 1
• Acute hemorrhagic stroke with SBP >180 mmHg: Immediate reduction to SBP between 130-180 mmHg 1
• Acute coronary event: Immediate reduction to SBP <140 mmHg, preferably with nitroglycerin 1
• Acute cardiogenic pulmonary edema: Immediate reduction to SBP <140 mmHg 1
• Acute aortic dissection: Immediate reduction to SBP <120 mmHg and heart rate <60 bpm 1

Treatment for Hypertensive Urgency (No End-Organ Damage)

• If no evidence of acute end-organ damage is found, oral antihypertensive therapy can be initiated 1, 5
• Combination therapy typically includes a renin-angiotensin system inhibitor, thiazide diuretic, and/or calcium channel blocker 5
• Close monitoring is required until goal BP is achieved 5

Common Pitfalls to Avoid

• Excessive rapid BP reduction can lead to cerebral, renal, or coronary ischemia 2
• Short-acting nifedipine is not recommended for initial treatment of hypertensive emergencies 2, 4
• Sodium nitroprusside should be used with caution due to its toxicity profile 4, 6
• Hydralazine, immediate-release nifedipine, and nitroglycerin should not be considered first-line therapies due to significant side effects 4

Follow-up Care

• Transition to oral antihypertensive therapy can usually be initiated after 6-12 hours of successful parenteral therapy 7
• Investigation for secondary causes of hypertension should be considered after stabilization 7
• Close monitoring and medication adherence are essential to prevent recurrence 5