What medications should be started for a patient with severe hypertension (blood pressure 190/130)?

Immediate Management of Severe Hypertension (BP 190/130)

For a patient presenting with BP 190/130 mmHg, immediately assess for acute target organ damage to distinguish between hypertensive emergency (requiring IV medications and ICU admission) versus hypertensive urgency (oral medications and outpatient management), then initiate combination oral antihypertensive therapy with two agents from different classes if no acute end-organ damage is present. 1, 2

Initial Assessment and Classification

Distinguish Emergency from Urgency

• Hypertensive emergency is defined as BP >180/120 mmHg WITH acute target organ damage (stroke, myocardial infarction, acute heart failure, acute kidney injury, hypertensive encephalopathy, aortic dissection, or eclampsia), requiring immediate BP reduction by approximately 25% within 1-2 hours using IV medications in an ICU setting. 1, 2

• Hypertensive urgency is defined as BP >180/120 mmHg WITHOUT signs or symptoms of acute target organ damage, allowing BP reduction over 24-48 hours with oral medications, typically managed as outpatient with close follow-up. 1, 2

• Rapidly assess for symptoms of acute target organ damage: chest pain, dyspnea, altered mental status, severe headache, visual changes, focal neurologic deficits, or back pain. 1

• Obtain ECG, basic metabolic panel, urinalysis, and troponin if acute target organ damage is suspected. 1

Pharmacologic Management for Hypertensive Urgency

Initial Combination Therapy Strategy

Start with two oral antihypertensive agents from complementary classes immediately, as monotherapy is insufficient for BP elevations >30 mmHg above target. 3

Recommended First-Line Combinations

• ACE inhibitor or ARB + Calcium Channel Blocker (CCB): This combination provides complementary mechanisms (vasodilation plus renin-angiotensin system blockade) and is the preferred initial dual therapy for most patients. 3, 4

  • Example: Lisinopril 10 mg daily + Amlodipine 5 mg daily 5, 6
  • Alternative: Losartan 50 mg daily + Amlodipine 5 mg daily 3, 6

• CCB + Thiazide Diuretic: This combination is particularly effective for Black patients and elderly patients with volume-dependent hypertension. 3, 4

  • Example: Amlodipine 5 mg daily + Hydrochlorothiazide 12.5-25 mg daily 3, 6
  • Alternative: Amlodipine 5 mg daily + Chlorthalidone 12.5 mg daily 6

Specific Dosing Recommendations

• Lisinopril: Start 10 mg once daily for hypertension; can titrate up to 40 mg daily (maximum 80 mg, though doses above 40 mg show minimal additional benefit). 5

• Amlodipine: Start 5 mg once daily; can increase to 10 mg daily if needed. 3, 6

• Hydrochlorothiazide: Start 12.5-25 mg once daily; maximum 50 mg daily. 5, 6

• Chlorthalidone: Start 12.5-25 mg once daily (preferred over hydrochlorothiazide due to longer duration of action). 6

Target Blood Pressure and Timeline

• Target BP: <140/90 mmHg minimum for most patients; ideally <130/80 mmHg for higher-risk patients (diabetes, chronic kidney disease, cardiovascular disease). 3

• Timeline for BP reduction in urgency: Reduce BP gradually over 24-48 hours to avoid precipitous drops that could cause ischemic complications. 2

• Follow-up: Reassess BP within 24-48 hours after initiating therapy, then weekly until controlled, then monthly for medication titration. 3

• Goal: Achieve target BP within 3 months of initiating or modifying therapy. 3, 4

When to Add a Third Agent

• If BP remains uncontrolled after optimizing doses of two agents (typically after 2-4 weeks), add a third agent from the remaining first-line class to achieve guideline-recommended triple therapy. 3, 4

• Triple therapy combination: ACE inhibitor/ARB + CCB + Thiazide diuretic represents the evidence-based approach for resistant hypertension. 3, 4

• Example progression: Lisinopril 20-40 mg + Amlodipine 10 mg + Hydrochlorothiazide 25 mg or Chlorthalidone 12.5-25 mg. 4, 6

Critical Pitfalls to Avoid

• Do not use immediate-release nifedipine, hydralazine, or nitroglycerin for hypertensive urgency, as these cause unpredictable and potentially dangerous BP drops. 1

• Do not reduce BP too rapidly in hypertensive urgency (>25% reduction in first hour), as this increases risk of stroke, myocardial infarction, and acute kidney injury from hypoperfusion. 1, 2

• Do not start monotherapy when BP is >30 mmHg above target, as combination therapy is more effective than dose escalation of a single agent. 3

• Do not combine ACE inhibitor with ARB, as this increases adverse events (hyperkalemia, acute kidney injury) without additional BP benefit. 3, 4

• Verify medication adherence before assuming treatment failure, as non-adherence is the most common cause of apparent resistant hypertension. 3, 7

• Screen for secondary causes if BP remains uncontrolled despite triple therapy at optimal doses, or if patient is young (<30 years) with severe hypertension. 7

Monitoring Parameters

• Renal function and electrolytes: Check baseline and 2-4 weeks after initiating ACE inhibitor/ARB or diuretic to detect hyperkalemia, hypokalemia, or acute kidney injury. 3

• Home BP monitoring: Confirm sustained hypertension with home readings (target <135/85 mmHg) to exclude white coat hypertension. 3

• Assess for side effects: Monitor for peripheral edema with CCBs (may be attenuated by adding ACE inhibitor/ARB), cough with ACE inhibitors, and electrolyte disturbances with diuretics. 3, 4

Lifestyle Modifications (Additive to Medications)

• Sodium restriction: <1500 mg/day or reduce by at least 1000 mg/day, providing 5-10 mmHg BP reduction. 3, 6

• Potassium supplementation: 3500-5000 mg/day through diet (fruits, vegetables), providing 4-5 mmHg BP reduction. 3, 6

• Weight loss: Target ideal body weight or minimum 1 kg reduction, providing 5-20 mmHg BP reduction per 10 kg lost. 3, 6

• Physical activity: 90-150 minutes/week of aerobic exercise, providing 5-8 mmHg BP reduction. 3, 6

• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women, providing 2-4 mmHg BP reduction. 3, 6

• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy, reduced saturated fat, providing 8-14 mmHg BP reduction. 3, 6

Special Populations and Comorbidities

• Diabetes with albuminuria: Prefer ACE inhibitor or ARB as first agent for renoprotection. 3

• Chronic kidney disease: Prefer ACE inhibitor or ARB (use ARB if ACE inhibitor not tolerated due to cough). 3

• Heart failure with reduced ejection fraction: Use guideline-directed medical therapy beta-blockers plus ACE inhibitor/ARB; avoid non-dihydropyridine CCBs (diltiazem, verapamil). 3

• Coronary artery disease: Prefer beta-blockers plus ACE inhibitor/ARB; can add dihydropyridine CCB for additional BP control. 3

• Post-stroke: Prefer thiazide diuretic, ACE inhibitor, or ARB; target <130/80 mmHg (<140/80 in elderly). 3

• Black patients: CCB + thiazide diuretic combination may be more effective than CCB + ACE inhibitor/ARB. 3, 4