What is the best course of action for an elderly female patient with a history of hypertension presenting with severe hypertension, nausea, vomiting, dizziness, and vertigo?

Management of Elderly Female with Severe Hypertension and Vertigo

This patient requires immediate evaluation to distinguish between a hypertensive emergency (requiring ICU admission and IV therapy) versus a hypertensive urgency or peripheral vestibular disorder, with the key determinant being presence or absence of acute target organ damage.

Critical Initial Assessment

First, determine if this is a true hypertensive emergency by evaluating for acute target organ damage:

• Neurological examination: Assess for altered mental status, confusion, focal neurological deficits, or signs of hypertensive encephalopathy—not just dizziness 1, 2
• Cardiac evaluation: Check for chest pain, acute pulmonary edema, or signs of acute heart failure 1, 3
• Fundoscopic examination: Look for papilledema, hemorrhages, or exudates indicating hypertensive retinopathy 1, 4
• Renal function: Obtain creatinine, electrolytes, and urinalysis to assess for acute kidney injury 3
• ECG and cardiac biomarkers: Rule out acute myocardial infarction 3

Critical distinction: The presence of isolated vertigo and vomiting without other signs of target organ damage suggests this may be a peripheral vestibular disorder (benign positional vertigo, vestibular neuritis) coinciding with severe hypertension, rather than a true hypertensive emergency 2.

If Hypertensive Emergency (Target Organ Damage Present)

Admit to ICU immediately for continuous arterial blood pressure monitoring and parenteral therapy 1, 3:

• Initial BP reduction goal: Reduce mean arterial pressure by 20-25% within the first hour (not to normal), then target 160/100-110 mmHg over the next 2-6 hours 1, 3, 5
• First-line IV medications:
  • Nicardipine: 5-15 mg/hr IV infusion (preferred for most hypertensive emergencies) 1, 3, 6
  • Labetalol: 20-80 mg IV bolus every 10 minutes or continuous infusion 1, 3
• Avoid: Short-acting nifedipine (risk of precipitous BP drops causing stroke or MI) 1, 3, 5
• Monitor continuously: Neurological status, cardiac function, renal function, and for excessive BP drops that could cause end-organ ischemia 3

If Hypertensive Urgency (No Target Organ Damage)

Initiate oral antihypertensive therapy with gradual BP reduction over 24-48 hours—do NOT use IV medications or hospitalize unless organ damage develops 5:

• First-line oral agents:
  • Captopril: 6.25-12.5 mg orally (low dose to avoid precipitous drops) 5
  • Labetalol: Oral dosing with combined alpha/beta blockade 5
  • Extended-release nifedipine: (never short-acting) 5
• BP reduction target: No more than 25% reduction in first hour, then aim for <160/100-110 mmHg over 2-6 hours 1, 5
• Observation: Monitor for at least 2 hours after initiating oral medication 5
• Disposition: Outpatient management with follow-up within 24 hours 5

Special Considerations for Elderly Patients

Age-related factors that modify management:

• Test for orthostatic hypotension before initiating or intensifying therapy (measure BP after 5 minutes sitting/lying, then at 1 and 3 minutes standing) 1
• Consider frailty status: If moderately-to-severely frail, use more conservative BP targets and slower titration 1
• Preferred agents for elderly: Long-acting dihydropyridine calcium channel blockers or RAS inhibitors, followed by low-dose diuretics if needed 1
• Avoid in elderly: Beta-blockers (unless compelling indication) and alpha-blockers 1

Management of Concurrent Vertigo

Address the vestibular symptoms while managing BP:

• If vertigo is positional and consistent with benign paroxysmal positional vertigo, perform Epley maneuver after BP stabilization
• Provide antiemetics (ondansetron or meclizine) for symptomatic relief of nausea/vomiting
• Ensure adequate hydration, as volume depletion can worsen both vertigo and hypertension

Critical Pitfalls to Avoid

• Do not lower BP too rapidly: Excessive drops can precipitate cerebral, renal, or coronary ischemia, especially in elderly patients with chronic hypertension and altered autoregulation 1, 5
• Do not use short-acting nifedipine: Associated with uncontrolled BP falls, stroke, and death 1, 3, 5
• Do not assume hypertensive emergency based on BP alone: The presence of symptoms indicating acute organ damage—not the BP number—defines a true emergency 1, 2
• Do not ignore medication non-adherence: This is the most common trigger for hypertensive crises and must be addressed 1, 5, 4

Post-Stabilization Management

• Screen for secondary hypertension causes: 20-40% of malignant hypertension cases have secondary causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) 3, 5
• Transition to oral therapy: Once stabilized, use combination therapy with RAS blockers, calcium channel blockers, and diuretics for long-term management 3
• Close follow-up: At least monthly until target BP achieved 5