What is the acute management for a patient with uncontrolled hypertension, presenting with a blood pressure of 200/110 mmHg, after being previously controlled at 160/90 mmHg?

Acute Management of Hypertensive Emergency (BP 200/110 mmHg)

This patient requires immediate ICU admission with continuous blood pressure monitoring and intravenous antihypertensive therapy, as the acute rise from 160/90 to 200/110 mmHg constitutes a hypertensive emergency requiring urgent intervention. 1, 2

Immediate Assessment and Triage

First, determine if target organ damage is present, as this distinguishes a hypertensive emergency (requiring immediate IV therapy) from hypertensive urgency (manageable with oral agents). 1, 2

Critical Signs of Target Organ Damage to Assess:

• Neurologic: Altered mental status, severe headache, visual disturbances, focal deficits, seizures (hypertensive encephalopathy or stroke) 3, 1
• Cardiac: Chest pain, dyspnea, pulmonary edema (acute coronary syndrome or heart failure) 1, 2
• Renal: Acute kidney injury, hematuria, proteinuria 1, 2
• Vascular: Chest/back pain radiating to back (aortic dissection) 1, 2
• Retinal: Fundoscopy for papilledema, hemorrhages, exudates 1, 2

Essential Laboratory Tests:

• Complete blood count, creatinine, electrolytes (sodium, potassium), LDH, haptoglobin, urinalysis with microscopy, troponins, ECG 1, 2
• These tests identify thrombotic microangiopathy, acute kidney injury, myocardial injury, and hemolysis 1, 2

Treatment Algorithm

If Target Organ Damage Present (Hypertensive Emergency):

Admit to ICU immediately with arterial line for continuous BP monitoring. 1, 2

Blood Pressure Reduction Target: Reduce mean arterial pressure by 20-25% over the first hour, NOT to normal values. 3, 1, 2 Patients with chronic hypertension have altered autoregulation—acute normalization causes cerebral, renal, or coronary ischemia. 1

First-Line IV Medication - Nicardipine:

• Start at 5 mg/hr IV infusion 3, 4
• Titrate by 2.5 mg/hr every 15 minutes up to maximum 15 mg/hr until desired BP reduction achieved 4
• For more rapid control, can titrate every 5 minutes 4
• Nicardipine is preferred due to predictable, titratable effect with rapid onset 1, 5, 6

Alternative First-Line Agent - IV Labetalol:

• Initial dose: 20 mg IV over 2 minutes 1
• Can repeat 20-80 mg every 10 minutes up to 300 mg total 1
• Particularly effective for renal involvement 1

If NO Target Organ Damage (Hypertensive Urgency):

Reduce BP gradually over 24-48 hours with oral agents. 1, 2 This can be managed outpatient if adequate follow-up is available. 7

Oral medication options:

• Captopril, labetalol, or extended-release nifedipine 2, 8
• Avoid short-acting nifedipine due to unpredictable rapid BP drops and reflex tachycardia 1, 2, 6

Critical Pitfalls to Avoid

Do NOT reduce BP to normal acutely (except in aortic dissection or pulmonary edema). 1, 7 A 20-25% reduction in the first hour is the target for most presentations. 3, 1, 2

Avoid excessive BP drops >70 mmHg acutely, as this associates with acute renal injury and neurological deterioration. 1

Do NOT use:

• Immediate-release nifedipine (unpredictable effects) 5, 6
• Sodium nitroprusside as first-line (significant toxicity) 5, 6
• Hydralazine or nitroglycerin as first-line 5, 6

Monitoring During Treatment

• Continuous arterial BP monitoring in ICU setting 1
• Monitor for hypotension or tachycardia—if occurs, stop infusion and restart at lower dose (3-5 mg/hr) once stabilized 4
• Change peripheral IV site every 12 hours if not using central line 4

After Stabilization

Screen for secondary hypertension causes (renal artery stenosis, pheochromocytoma, primary aldosteronism), as 20-40% of malignant hypertension cases have secondary causes. 1, 2

Assess medication compliance, the most common trigger for hypertensive emergencies. 1

Transition to oral therapy with combination of RAS blockers, calcium channel blockers, and diuretics targeting long-term BP control. 1