What is the initial treatment for a patient presenting to the Emergency Room (ER) with new hypertension?

Treatment for New Hypertension in the Emergency Room

For patients presenting to the Emergency Room with new hypertension without evidence of target organ damage, oral antihypertensive medication should be initiated with blood pressure reduction of no more than 25% within the first hour, followed by gradual reduction to 160/100 mmHg over the next 2-6 hours. 1, 2

Differentiating Hypertensive Urgency vs. Emergency

• Hypertensive urgency: Severe BP elevation (>180/120 mmHg) without evidence of new or progressive target organ damage 1, 2
• Hypertensive emergency: Severe BP elevation with evidence of new or worsening target organ damage (encephalopathy, stroke, acute heart failure, etc.) 1
• Assessment should include evaluation for symptoms of target organ damage and appropriate diagnostic testing 2

Initial Management for Hypertensive Urgency

• Avoid rapid BP reduction as this can lead to cardiovascular complications 1
• Controlled BP reduction to safer levels without risk of hypotension should be the therapeutic goal 1
• For patients without compelling conditions, SBP should be reduced by no more than 25% within the first hour 1
• Then, if stable, aim for BP <160/100 mmHg within the next 2-6 hours 1, 2
• Cautiously normalize BP over the following 24-48 hours 1

Recommended Oral Medications

• First-line oral medications include:
  • Captopril (ACE inhibitor) 1, 2
  • Labetalol (combined alpha and beta-blocker) 1, 2
  • Extended-release nifedipine (calcium channel blocker) 1, 2
• For new hypertension patients without prior treatment, starting doses:
  • Lisinopril: Initial dose 10 mg once daily 3
  • Losartan: Initial dose 50 mg once daily 4

Monitoring and Follow-up

• An observation period of at least 2 hours is recommended to evaluate BP lowering efficacy and safety 1, 2
• Avoid short-acting nifedipine as it can cause unpredictable and excessive drops in blood pressure 2, 5
• Excessive falls in pressure may precipitate renal, cerebral, or coronary ischemia 2

Management of Hypertensive Emergency

• Requires immediate BP reduction (not necessarily to normal) to prevent or limit further target organ damage 1
• Intravenous medications are preferred in true hypertensive emergencies 1
• First-line IV medications include labetalol, nicardipine, or clevidipine 1
• Treatment is guided by the type of target organ damage present 1

Special Considerations

• In patients with autonomic hyperreactivity (e.g., cocaine intoxication), benzodiazepines should be initiated first 1
• For patients with coronary ischemia, nitroglycerin and aspirin are recommended 1
• In patients with adrenergic overstimulation due to pheochromocytoma, avoid labetalol 1

Long-term Management

• Address medication adherence issues, as many hypertensive urgencies result from non-compliance 2
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1
• Screen for secondary causes of hypertension in patients with recurrent hypertensive crises 2