What should be the target blood pressure (BP) in a patient with a hypertensive crisis upon arrival at the destination?

Management of Hypertensive Crisis in a 92-Year-Old Male

For a 92-year-old male with hypertensive crisis (BP 245/132), the target blood pressure upon arrival at your destination should be approximately 182/100 mmHg, representing a 25% reduction in mean arterial pressure from the initial value. 1

Understanding Hypertensive Crisis

• Hypertensive emergency is defined as severely elevated blood pressure (>180/120 mmHg) with evidence of acute target organ damage requiring immediate intervention 2, 1
• The patient's current BP of 245/132 mmHg meets criteria for hypertensive crisis, requiring careful management during transport 1
• The most important factor limiting morbidity and mortality is prompt and carefully considered therapy to safely reduce BP 3

Target Blood Pressure Goals

• The recommended approach is to reduce mean arterial pressure (MAP) by no more than 25% within the first hour 1
• For patients without compelling conditions (such as aortic dissection), reducing systolic BP by no more than 25% within the first hour is recommended, followed by cautious reduction over the next 24-48 hours 1
• Calculating a 25% reduction from initial MAP of 170 mmHg ((245+132+132)/3) would target approximately 127 mmHg MAP, corresponding to approximately 182/100 mmHg 1

Rationale for Controlled BP Reduction

• Excessive falls in pressure can precipitate renal, cerebral, or coronary ischemia, especially in elderly patients 1
• Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals 1
• Early SBP reduction of >60 mmHg in the first hour has been associated with increased proportion of patients with unfavorable outcomes 2
• The European Society of Cardiology notes that excessive acute drops in systolic BP may be associated with acute renal injury and early neurological deterioration 1

Special Considerations for Elderly Patients

• For elderly patients (>80 years), BP targets should be individualized based on frailty 2
• The patient's advanced age (92 years) warrants particular caution to avoid hypoperfusion of vital organs 1
• Monitoring for signs of organ hypoperfusion during BP reduction is essential in this age group 1

Monitoring During Transport

• Continuous monitoring of BP and assessment for signs of target organ damage is essential during transport 1
• Watch for symptoms such as altered mental status, chest pain, visual disturbances, or neurological deficits that may indicate worsening end-organ damage 1, 3
• If the patient develops signs of organ hypoperfusion during BP reduction, consider slowing the rate of BP reduction 1

Medication Considerations

• IV medications such as labetalol, nicardipine, or clevidipine are preferred for controlled BP reduction in hypertensive emergencies 1, 4
• Avoid medications like short-acting nifedipine, hydralazine, and nitroglycerin as first-line agents due to unpredictable BP reduction 5, 6
• Sodium nitroprusside should be avoided due to its toxicity profile, particularly in elderly patients 5, 6

Remember that the goal is not to normalize blood pressure immediately but to achieve a controlled reduction to prevent complications from either persistent severe hypertension or excessive BP lowering 1.