What should I do for a patient with severe hypertension (blood pressure 168/100)?

Management of Blood Pressure 168/100

This blood pressure reading (168/100 mmHg) does not constitute a hypertensive emergency and should be managed with oral antihypertensive medications with gradual reduction over 24-48 hours, not immediate aggressive lowering. 1, 2

Critical First Step: Assess for Target Organ Damage

The distinction between emergency and urgency determines your entire management approach:

• Check for signs of acute target organ damage including altered mental status, chest pain, shortness of breath, severe headache with neurological changes, visual disturbances, or acute kidney injury 1, 2
• A blood pressure of 168/100 mmHg is below the threshold for hypertensive crisis (>180/120 mmHg), making acute organ damage unlikely unless the patient was previously normotensive 1, 3
• Without evidence of acute organ damage, this is NOT a hypertensive emergency and does not require ICU admission or IV medications 1, 2

Recommended Management Approach

Immediate Actions

• Observe the patient for at least 2 hours after initiating or adjusting oral medication to evaluate blood pressure lowering efficacy and safety 2
• Target blood pressure reduction to 160/100 mmHg within 2-6 hours, then continue gradual reduction to goal over 24-48 hours 4, 2
• Do NOT reduce blood pressure by more than 25% in the first hour - excessive reduction can precipitate cerebral, renal, or coronary ischemia 4, 1

Medication Selection

• Use oral antihypertensive medications - IV medications are reserved for true hypertensive emergencies with organ damage 2
• Appropriate oral options include ACE inhibitors, ARBs, beta-blockers, or long-acting calcium channel blockers (extended-release formulations only) 2
• Start with low doses due to potential sensitivity, especially if the patient has chronic hypertension with altered autoregulation 2, 5
• AVOID short-acting nifedipine - it causes unpredictable, rapid blood pressure drops and reflex tachycardia 2, 6

Critical Pitfalls to Avoid

• Do not treat the number alone - many patients with acute pain, anxiety, or distress have transiently elevated blood pressure that normalizes when the underlying issue is addressed 2
• Avoid rapid, uncontrolled blood pressure lowering - patients with chronic hypertension have shifted autoregulation curves, and acute normalization causes end-organ hypoperfusion 1, 5
• Do not use IV medications for this blood pressure level without evidence of acute organ damage 2

Follow-Up Requirements

• Arrange close outpatient follow-up to ensure continued blood pressure control and medication compliance 2
• Address medication non-adherence - this is the most common trigger for severe hypertension 1
• Consider screening for secondary hypertension causes if blood pressure remains difficult to control, as 20-40% of severe hypertension cases have secondary causes 1

When to Escalate Care

Admit to ICU only if the patient develops signs of acute organ damage including hypertensive encephalopathy, acute stroke, acute coronary syndrome, acute heart failure, acute kidney injury, or aortic dissection 1