What is the likely diagnosis for a patient with severely elevated blood pressure (hypertension) of 220/110 mmHg?

Likely Diagnosis: Hypertensive Emergency vs. Hypertensive Urgency

The likely diagnosis depends critically on whether target organ damage is present—if acute organ damage exists with BP 220/110 mmHg, this is a hypertensive emergency requiring immediate ICU admission and IV therapy; if no organ damage is present, this is a hypertensive urgency manageable with oral medications as an outpatient. 1

Critical Distinguishing Factor

The presence or absence of acute target organ damage—not the absolute blood pressure number—determines the diagnosis and management approach. 1 A BP of 220/110 mmHg exceeds the threshold of 180/120 mmHg that defines a hypertensive crisis, but the severity is determined by organ involvement, not the BP level alone. 1, 2

If Hypertensive Emergency (With Organ Damage)

Target Organ Damage to Assess For:

• Neurologic: Hypertensive encephalopathy (altered mental status, headache, visual disturbances, seizures), intracranial hemorrhage, acute ischemic stroke 1
• Cardiac: Acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina 1
• Renal: Acute kidney injury, thrombotic microangiopathy (check creatinine, urinalysis for proteinuria and abnormal sediment) 1
• Vascular: Aortic dissection (assess for chest/back pain, pulse differentials) 1
• Ophthalmologic: Malignant hypertension with retinal hemorrhages, cotton wool spots, papilledema on fundoscopy 1

Immediate Management:

• ICU admission (Class I recommendation, Level B-NR) for continuous BP monitoring with arterial line and parenteral therapy 1
• First-line IV medications: Nicardipine (5 mg/hr, titrate by 2.5 mg/hr every 15 minutes, max 15 mg/hr) or labetalol 1, 3
• BP reduction target: Reduce mean arterial pressure by 20-25% within the first hour, then if stable to 160/100 mmHg over 2-6 hours, then cautiously to normal over 24-48 hours 1
• Critical pitfall: Avoid reducing BP to normal acutely—patients with chronic hypertension have altered cerebral autoregulation and acute normalization can cause cerebral, renal, or coronary ischemia 1

Essential Laboratory Tests:

• Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia 1
• Basic metabolic panel (creatinine, sodium, potassium) to evaluate renal function 1
• Lactate dehydrogenase and haptoglobin to detect hemolysis in thrombotic microangiopathy 1
• Urinalysis for protein and urine sediment examination 1
• Troponins if chest pain present 1
• ECG to assess for cardiac involvement 1

If Hypertensive Urgency (Without Organ Damage)

Clinical Presentation:

• Severely elevated BP (220/110 mmHg) WITHOUT acute organ damage 1
• May have non-specific symptoms: palpitations, headache, malaise, general feeling of illness 4
• No evidence of acute end-organ dysfunction on examination or testing 2

Management:

• Outpatient management with oral antihypertensive therapy and close follow-up 1
• No hospital admission or IV medications required 1
• BP reduction goal: Gradual lowering over 24-48 hours, NOT within minutes 4, 5
• Medication approach: Start or restart long-acting oral agents (combination of RAS blocker, thiazide diuretic, and/or calcium channel blocker) 6
• Important note: Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and rapid BP lowering may be harmful 1

Common Pitfalls to Avoid:

• Do not treat the BP number alone—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1
• Avoid immediate-release nifedipine—causes unpredictable precipitous BP drops and reflex tachycardia 1, 2
• Avoid excessive acute drops in systolic BP (>70 mmHg)—may precipitate acute renal injury, cerebral ischemia, or coronary ischemia 1
• Do not apply outpatient BP goals to acute inpatient management—evidence for aggressive inpatient BP lowering is limited and may cause harm 1

Post-Stabilization Evaluation:

• Screen for secondary hypertension (found in 20-40% of malignant hypertension cases): renal artery stenosis, pheochromocytoma, primary aldosteronism 1
• Address medication non-compliance—the most common trigger for hypertensive emergencies 1
• Assess for contributing factors: sympathomimetics, cocaine, NSAIDs, steroids, immunosuppressants 1