What medication should be prescribed for a patient with severe hypertension (blood pressure 180/90 mmHg)?

Treatment of Severe Hypertension (180/90 mmHg)

For a patient with severe hypertension (180/90 mmHg), immediate initiation of combination therapy with two antihypertensive agents of different classes is strongly recommended. 1

Classification and Assessment

• Blood pressure of 180/90 mmHg is classified as Stage 2 hypertension (≥160/100 mmHg) requiring immediate treatment 1
• This level approaches hypertensive crisis territory, which is defined as systolic BP >180 mmHg or diastolic BP >120 mmHg 1
• Evaluate for signs of hypertensive emergency (acute target organ damage) including:
  • Neurological symptoms (encephalopathy, stroke)
  • Cardiovascular complications (acute heart failure, aortic dissection)
  • Renal dysfunction
  • Retinal hemorrhages or exudates 2

Initial Treatment Approach

For Patients WITHOUT Evidence of Hypertensive Emergency:

• Start with combination therapy using two first-line agents from different classes 1
• Recommended first-line combination for non-Black patients:
  • ACE inhibitor or ARB + calcium channel blocker (CCB) OR
  • ACE inhibitor or ARB + thiazide/thiazide-like diuretic 1
• Recommended first-line combination for Black patients:
  • ARB + dihydropyridine CCB OR
  • Dihydropyridine CCB + thiazide/thiazide-like diuretic 1

For Patients WITH Evidence of Hypertensive Emergency:

• Admit to intensive care unit for continuous BP monitoring and parenteral antihypertensive therapy 1
• First-line IV medications based on specific organ damage:
  • For most hypertensive emergencies: IV labetalol or nicardipine 1
  • For pulmonary edema: IV nitroprusside or nitroglycerin 1
  • For aortic dissection: IV esmolol plus nitroprusside or nitroglycerin 1

Specific Medication Recommendations

Oral Therapy (for non-emergency situations):

1. ACE inhibitor (e.g., lisinopril):

   • Starting dose: 10 mg once daily
   • Usual dosage range: 20-40 mg daily 3
   • Advantages: Effective, reduces cardiovascular events, renoprotective 3

2. Calcium Channel Blocker (e.g., amlodipine):

   • Starting dose: 5 mg once daily
   • Advantages: Effective in both Black and non-Black patients 1

3. Thiazide-like Diuretic (e.g., chlorthalidone):

   • Starting dose: 12.5-25 mg once daily
   • Advantages: Proven reduction in cardiovascular disease 1

Treatment Goals and Monitoring

• Target BP reduction:
  • Initial goal: Reduce BP by at least 20/10 mmHg 1
  • Ultimate goal: <130/80 mmHg for most patients 1
• Monitor BP control and aim to achieve target within 3 months 1
• Schedule follow-up within 1 month to assess response and adjust therapy as needed 1

Important Considerations and Pitfalls

• Avoid rapid BP reduction in non-emergency situations as this can lead to hypoperfusion of vital organs 1
• Do not use short-acting nifedipine for severe hypertension due to risk of precipitous BP drops 1, 4
• Consider single-pill combinations to improve adherence and simplify regimen 1
• Evaluate for secondary causes of hypertension if BP remains difficult to control despite multiple medications 1
• For resistant hypertension, consider adding spironolactone as a fourth-line agent 1

Special Populations

• Elderly patients: May require more careful BP lowering; individualize based on frailty 1
• Black patients: Typically respond better to CCBs and thiazide diuretics than to ACE inhibitors or ARBs as monotherapy 1
• Patients with diabetes or CKD: ACE inhibitors or ARBs are preferred first-line agents 1