What to do with a 75-year-old female patient with severely elevated blood pressure (hypertension) and mildly raised troponin levels, who has missed her blood pressure (BP) medications for 2 days?

Management of Hypertensive Crisis with Elevated Troponin

This patient requires immediate hospitalization to the ICU for management of a hypertensive emergency with evidence of cardiac injury (elevated troponin), with controlled BP reduction using IV antihypertensives to lower SBP by no more than 25% in the first hour, then to 160/100 mmHg over 2-6 hours. 1

Classification: Hypertensive Emergency vs Urgency

This is a hypertensive emergency, not urgency, based on: 1

• Severely elevated BP (200/100 mmHg, exceeding 180/120 mmHg threshold) 1
• Evidence of acute target organ damage: Elevated troponin (48, then 46) indicates acute myocardial injury, which qualifies as acute coronary syndrome presentation 1
• The persistently elevated troponin on repeat testing confirms ongoing cardiac damage, not a spurious result 1

Key distinction: Patients with severe BP elevation WITHOUT acute organ damage can be managed outpatient with oral medications, but troponin elevation changes this to an emergency requiring immediate intervention. 2, 3

Immediate Management Steps

1. Hospital Admission to ICU

Admit immediately to intensive care unit for: 1

• Continuous BP monitoring
• Cardiac monitoring for ongoing ischemia
• Parenteral antihypertensive administration
• Serial troponin monitoring

2. Blood Pressure Reduction Strategy

For patients without compelling conditions requiring faster reduction (aortic dissection, eclampsia, pheochromocytoma crisis), follow this timeline: 1

• First hour: Reduce SBP by no more than 25% (target ~150 mmHg)
• Next 2-6 hours: If stable, reduce to 160/100 mmHg
• Following 24-48 hours: Cautiously reduce to normal range

Rationale: Aggressive BP lowering can precipitate cerebral, coronary, or renal hypoperfusion, especially in patients with chronic hypertension who have adapted to higher pressures. 1, 2

3. IV Antihypertensive Selection

First-line agents for this presentation (acute coronary event with troponin elevation): 1, 4

Nicardipine (preferred):

• Initial: 5 mg/hr IV infusion
• Titrate by 2.5 mg/hr every 15 minutes (or every 5 minutes for faster control)
• Maximum: 15 mg/hr
• Advantages: Titratable, predictable, no cyanide toxicity risk 4, 5

Labetalol (alternative):

• Initial: 0.3-1.0 mg/kg (maximum 20 mg) slow IV every 10 minutes
• Or continuous infusion: 0.4-1.0 mg/kg/hr up to 3 mg/kg/hr
• Provides both alpha and beta blockade 1

Nitroglycerin (if active ischemia suspected):

• Initial: 5 mcg/min
• Increase by 5 mcg/min every 3-5 minutes to maximum 20 mcg/min
• Particularly useful if concurrent pulmonary edema 1

4. Cardiac Workup for Troponin Elevation

Essential investigations: 1

• Serial troponins (every 3-6 hours initially)
• Continuous ECG monitoring for ST-segment changes
• Transthoracic echocardiogram to assess cardiac function and wall motion abnormalities
• Consider cardiology consultation for potential acute coronary syndrome management

Important: The mildly elevated troponin (48,46) with no ECG changes may represent: 1

• Type 2 MI (supply-demand mismatch from severe hypertension)
• Hypertensive cardiomyopathy with strain
• Early acute coronary syndrome

5. Avoid Common Pitfalls

Do NOT use: 5, 2, 6

• Oral short-acting nifedipine: Associated with unpredictable, precipitous BP drops and adverse cardiovascular events 5
• Aggressive IV boluses "as needed": 84.5% of IV antihypertensive doses are inappropriately given for SBP <180 mmHg, and 32.6% cause excessive BP reduction >25% within 6 hours 6
• Sodium nitroprusside as first-line: Risk of cyanide toxicity, especially with prolonged use 5

6. Monitoring Parameters

Critical monitoring during IV therapy: 7, 4

• BP every 5-15 minutes during titration
• Heart rate continuously
• Renal function (creatinine) - watch for acute kidney injury
• Electrolytes (potassium) - especially if adding ACE inhibitor/ARB later
• Cardiac rhythm and troponin trends
• Signs of hypoperfusion (mental status, urine output)

7. Transition to Oral Therapy

Once BP stabilized (typically 24-48 hours): 7, 4

• Restart her home BP medications
• Optimize regimen before discharge: Add third agent (ACE inhibitor or ARB) to prevent recurrence 7
• If she was on suboptimal doses (e.g., HCTZ <25mg, amlodipine <10mg), increase to therapeutic doses 7
• For nicardipine transition: Start oral antihypertensive 1 hour before stopping IV infusion 4

8. Address Medication Non-Adherence

Critical for preventing recurrence: 2, 3

• Identify barriers to adherence (cost, side effects, complexity, cultural factors)
• Simplify regimen with once-daily dosing and single-pill combinations when possible 7
• Arrange close outpatient follow-up within 2-4 weeks 7
• Consider social work consultation for medication access issues

Special Consideration: Visiting from Nigeria

Practical factors: 7

• Ensure adequate medication supply for remainder of visit
• Provide written medication list with generic names (availability may differ)
• Arrange follow-up with her primary physician in Nigeria
• Consider travel insurance/medical evacuation coverage discussion