What is the treatment for severe hypertension?

Treatment of Severe Hypertension

The treatment of severe hypertension depends critically on whether acute target organ damage is present: hypertensive emergencies require immediate ICU admission with IV antihypertensives (nicardipine or labetalol first-line), while hypertensive urgencies can be managed with oral medications and outpatient follow-up. 1, 2

Critical First Step: Distinguish Emergency from Urgency

Assess immediately for acute target organ damage to determine the appropriate treatment pathway 1, 2:

Hypertensive Emergency (BP >180/120 mmHg WITH organ damage):

• Neurologic: hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke 1
• Cardiac: acute MI, acute left ventricular failure with pulmonary edema, unstable angina 1
• Vascular: aortic dissection 1
• Renal: acute kidney injury, thrombotic microangiopathy 1
• Ophthalmologic: papilledema, retinal hemorrhages, cotton wool spots 1

Hypertensive Urgency (BP >180/120 mmHg WITHOUT organ damage):

• Severe headache, epistaxis, anxiety without evidence of acute organ dysfunction 3, 4

Without treatment, hypertensive emergencies carry 79% mortality at 1 year with median survival of only 10.4 months 1, 2

---

Management of Hypertensive Emergency

Immediate Actions

Admit to ICU immediately for continuous arterial BP monitoring and IV antihypertensive therapy (Class I recommendation, Level B-NR) 1, 2

Blood Pressure Targets

Standard approach for most emergencies 1, 2:

• First hour: Reduce mean arterial pressure by 20-25%
• Next 2-6 hours: If stable, reduce to 160/100 mmHg
• Next 24-48 hours: Cautiously normalize BP

Critical caveat: Avoid excessive BP drops >70 mmHg systolic or >25% reduction in first hour, which can precipitate cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation 1, 2

Condition-Specific Targets

Aortic dissection 1, 2:

• Target: SBP <120 mmHg AND heart rate <60 bpm immediately
• First-line: Esmolol plus nitroprusside or nitroglycerin

Acute coronary syndrome or cardiogenic pulmonary edema 1, 2:

• Target: SBP <140 mmHg immediately
• First-line: Nitroglycerin IV (5-10 mcg/min, titrate by 5-10 mcg/min every 5-10 minutes)

Acute ischemic stroke 1:

• Avoid BP reduction within first 5-7 days unless BP >220/120 mmHg
• If BP ≥220/110 mmHg: Reduce by approximately 15% over first 24 hours

Acute intracerebral hemorrhage 1:

• If SBP ≥220 mmHg: Carefully lower to 140-160 mmHg within 6 hours to prevent hematoma expansion
• If SBP <220 mmHg: Do not lower immediately

Hypertensive encephalopathy or malignant hypertension with renal failure 1, 2:

• Target: 20-25% reduction in mean arterial pressure over several hours
• First-line: Labetalol IV

First-Line IV Medications

Nicardipine (preferred for most emergencies) 1, 2, 5:

• Advantages: Predictable titration, maintains cerebral blood flow, does not increase intracranial pressure
• Dosing: Start 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes to maximum 15 mg/hr
• For rapid reduction: Titrate every 5 minutes
• Preparation: Dilute 25 mg vial with 240 mL compatible IV fluid to achieve 0.1 mg/mL concentration 5
• Administration: Via central line or large peripheral vein; change infusion site every 12 hours if peripheral 5

Labetalol (excellent for renal involvement, encephalopathy) 1, 2:

• Dosing: 0.25-0.5 mg/kg IV bolus OR 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/hr maintenance
• Contraindications: Reactive airways disease, COPD, second/third-degree heart block, bradycardia, decompensated heart failure 3
• Caution: Use cautiously in sympathomimetic-induced hypertension (cocaine, methamphetamine) 3

Clevidipine (alternative calcium channel blocker) 1:

• Dosing: Start 1-2 mg/hr, double every 90 seconds until BP approaches target, then increase by less than double every 5-10 minutes, maximum 32 mg/hr

Medications to Avoid

Do NOT use 1, 6:

• Immediate-release nifedipine: Unpredictable precipitous BP drops, reflex tachycardia
• Sodium nitroprusside: Risk of cyanide toxicity (use only as last resort if other agents fail)
• Hydralazine: Unpredictable effects, significant adverse effects

---

Management of Hypertensive Urgency

Treatment Approach

Initiate oral antihypertensive therapy with outpatient follow-up - hospital admission and IV medications are NOT required 2, 3

Blood Pressure Targets

• First hour: Reduce by no more than 25%
• Next 2-6 hours: If stable, target <160/100-110 mmHg
• Long-term: Achieve <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 2, 3

Oral Medication Selection

For Non-Black Patients 7, 2:

1. Start low-dose ACE inhibitor or ARB
2. Add dihydropyridine calcium channel blocker if needed
3. Titrate to full doses before adding third agent
4. Add thiazide or thiazide-like diuretic as third-line

For Black Patients 7, 2:

1. Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic
2. Titrate to full doses
3. Add the missing component (diuretic or ARB/ACEI) as third-line

Specific oral agents for urgency 3:

• Captopril: Particularly useful with high plasma renin activity (contraindicated in pregnancy, bilateral renal artery stenosis)
• Labetalol: Effective but avoid in reactive airways, heart block, bradycardia
• Long-acting nifedipine: Extended-release formulations only (NOT immediate-release)

Monitoring and Follow-up

• Observe for at least 2 hours after initiating therapy to evaluate efficacy and safety 3
• Follow-up within 1-2 weeks to adjust therapy and ensure BP control 2, 3
• Address medication non-compliance, the most common trigger for hypertensive urgencies 1

---

Post-Stabilization Management

After stabilizing a hypertensive emergency, gradually transition to oral antihypertensives 2:

• Combination of RAS blockers, calcium channel blockers, and diuretics
• Long-term target: SBP 120-129 mmHg for most adults
• Screen for secondary hypertension causes (renal artery stenosis, pheochromocytoma, primary aldosteronism), as 20-40% of malignant hypertension cases have secondary causes 1, 2

---

Critical Pitfalls to Avoid

Do not lower BP to "normal" acutely - patients with chronic hypertension have altered cerebral, renal, and cardiac autoregulation and cannot tolerate acute normalization 1, 2

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

Do not use oral medications for initial management of hypertensive emergency - IV therapy is required 1

Do not delay assessment for target organ damage - the presence or absence of acute organ damage determines the entire treatment approach 1, 2