How to manage a hypertensive patient with symptoms of giddiness, blurred vision, and evidence of multifocal old infarcts on imaging, who also has fungal sinusitis and is on multiple medications including antihypertensives, antiplatelets, and statins?

Management of Hypertensive Emergency with Neurological Manifestations and Multifocal Infarcts

This patient requires immediate hospitalization for parenteral blood pressure reduction to prevent further end-organ damage, with a target BP reduction of 20-25% within the first hour, avoiding overly aggressive lowering that could worsen cerebral perfusion in the setting of chronic hypertension and prior strokes. 1

Immediate Classification and Risk Stratification

This 48-year-old woman presents with a hypertensive emergency (BP 256/121 mmHg) rather than urgency, evidenced by:

• Acute neurological symptoms (giddiness, blurred vision, bilateral internuclear ophthalmoplegia, gait ataxia) 1
• New-onset diabetes (HGT 20.4 mmol/L) with osmotic symptoms 1
• Background of multifocal old infarcts and small vessel disease on imaging 1

The presence of neurological deficits with severely elevated BP constitutes acute hypertension-mediated organ damage requiring urgent intervention 1, 2. Her defaulted hypertension follow-up likely contributed to this crisis 1.

Blood Pressure Targets and Timeline

Target BP reduction: Decrease by 20-25% in the first hour, then gradually to 160/100 mmHg over 2-6 hours 1, 2.

Critical considerations for this patient:

• Do NOT normalize BP acutely - patients with chronic hypertension have altered cerebral autoregulation curves 2
• Rapid normalization risks cerebral hypoperfusion and stroke extension in patients with prior infarcts 1
• Her multifocal old infarcts indicate chronic cerebrovascular disease requiring cautious BP lowering 1
• Avoid diastolic BP <60 mmHg given her age (48 years) and vascular disease 1

Immediate Management Steps

1. Hospital Admission and Monitoring

• Mandatory ICU/monitored bed admission for hypertensive emergency 1, 3
• Continuous intraarterial BP monitoring preferred for parenteral therapy 3
• Neurological assessments every 1-2 hours during acute phase 1

2. Parenteral Antihypertensive Selection

First-line agent: Intravenous nicardipine 1, 3

• Potent arteriolar vasodilator without direct myocardial depression 3
• Titratable infusion allows precise BP control 3
• Does not cause cerebral vasoconstriction (unlike some agents) 3
• Starting dose: 5 mg/hour, increase by 2.5 mg/hour every 5-15 minutes to maximum 15 mg/hour 3

Alternative: Intravenous labetalol 1

• Combined alpha/beta blockade provides smooth BP reduction 1
• Bolus: 20 mg IV over 2 minutes, then 40-80 mg every 10 minutes (maximum 300 mg) 1
• Or continuous infusion: 0.5-2 mg/minute 1

Avoid sodium nitroprusside despite its reliability 3 - should be used cautiously in patients with impaired cerebral flow and her multifocal infarcts represent significant cerebrovascular disease 3.

3. Concurrent Diabetes Management

Her severe hyperglycemia (HGT 20.4 mmol/L) requires:

• Insulin infusion protocol targeting gradual glucose reduction to 8-10 mmol/L initially 1
• Avoid rapid glucose correction which can worsen cerebral edema 1
• Monitor for hyperosmolar state given polyuria/polydipsia 1

4. Address the Fungal Sinusitis

The left maxillary fungal sinusitis identified on imaging requires:

• ENT consultation for potential surgical debridement 1
• Antifungal therapy (likely amphotericin B or voriconazole depending on organism) 1
• This may be contributing to her neurological symptoms and requires definitive treatment 1

Transition to Oral Therapy (24-48 hours)

Once BP stabilized and patient tolerating oral intake:

Optimize her current regimen which already includes appropriate agents:

• Continue amlodipine 10 mg daily (dihydropyridine CCB) 1, 4
• Continue terazosin 7.5 mg BD (alpha-blocker, though not first-line) 1
• Add or optimize ACE inhibitor/ARB - not currently prescribed 1
  • Start perindopril 4 mg daily or ramipril 5 mg daily 1
  • ARBs equally effective if ACE inhibitor not tolerated 1
• Add thiazide-like diuretic - not currently prescribed 1
  • Indapamide 2.5 mg daily preferred 1
  • Essential for resistant hypertension management 1

Continue dual antiplatelet therapy (aspirin 100 mg + clopidogrel 75 mg) given multifocal infarcts - appropriate for secondary stroke prevention 1.

Continue atorvastatin 40 mg - appropriate for vascular disease 1.

Long-term BP Targets

Target: <130/80 mmHg 1

• Given her diabetes, prior strokes, and small vessel disease, she qualifies as high cardiovascular risk 1
• Some evidence supports even lower targets (<120/80 mmHg) in high-risk patients 1
• However, avoid diastolic <60 mmHg given cerebrovascular disease 1

Critical Pitfalls to Avoid

1. Do not use sublingual nifedipine - unpredictable absorption and excessive BP drops risk stroke 2, 3
2. Avoid clonidine - associated with increased mortality in similar patients 1
3. Do not use non-dihydropyridine CCBs (diltiazem/verapamil) if heart failure develops 1
4. Terazosin (alpha-blocker) should be reconsidered - ALLHAT trial showed increased heart failure risk with doxazosin 1; use only if other agents inadequate 1
5. Do not reduce BP >25% in first hour - risks watershed infarcts in chronic hypertension 1, 2

Follow-up Strategy

Intensive outpatient monitoring post-discharge:

• Weekly BP checks for first month 1
• Monthly visits until target BP achieved and maintained 1
• Monitor for regression of hypertension-mediated organ damage: proteinuria, renal function, repeat neuroimaging at 3 months 1
• Address medication adherence - her defaulted follow-up was likely contributory 1
• Lifestyle modifications: sodium restriction <2g/day, weight management (BMI target 18.5-24.9), regular exercise 1

Prognosis: Patients with hypertensive emergencies remain at significantly elevated cardiovascular risk even after treatment 1. Her multifocal infarcts and small vessel disease indicate substantial vascular damage requiring aggressive risk factor modification 1.