What are the treatment options for hypertension, hypertensive urgency, and hypertensive emergency?

Sample Orders for Hypertension, Hypertensive Urgency, and Hypertensive Emergency

Immediate Triage: Distinguish Emergency from Urgency

The critical first step is determining whether acute target organ damage is present—this distinction dictates whether the patient requires ICU admission with IV therapy versus outpatient oral management. 1, 2

Assessment for Target Organ Damage

Perform focused evaluation for:

• Neurologic: Altered mental status, headache with vomiting, visual disturbances, seizures, focal deficits 1, 2
• Cardiac: Chest pain, dyspnea, pulmonary edema 1, 2
• Vascular: Tearing chest/back pain (aortic dissection) 1
• Renal: Acute kidney injury, hematuria 1
• Ophthalmologic: Fundoscopy for papilledema, hemorrhages, cotton wool spots 1

Essential Laboratory Workup

Order immediately:

• CBC with platelets (assess for thrombocytopenia/microangiopathic hemolysis) 1, 2
• Comprehensive metabolic panel (creatinine, sodium, potassium for renal function/electrolytes) 1, 2
• LDH and haptoglobin (detect hemolysis in thrombotic microangiopathy) 1, 2
• Urinalysis with microscopy (proteinuria, RBC casts) 1, 2
• Troponin if chest pain present 1, 2
• ECG (assess for LVH, ischemia) 1, 2

Additional imaging based on presentation:

• Chest X-ray if pulmonary edema suspected 1
• CT/MRI brain if neurologic symptoms 1
• CT angiography if aortic dissection suspected 1

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Hypertensive Emergency Orders (BP >180/120 mmHg WITH Target Organ Damage)

Admission and Monitoring

Admit to ICU immediately for continuous arterial BP monitoring and parenteral therapy. 1, 2, 3

• Place arterial line for continuous BP monitoring 2
• Continuous cardiac monitoring 1
• Hourly neurologic checks 2
• Strict intake/output monitoring 1

IV Medication Orders by Clinical Presentation

For Most Hypertensive Emergencies (Malignant HTN, Hypertensive Encephalopathy, Renal Failure):

Nicardipine IV infusion 1, 2, 3, 4:

• Start at 5 mg/hr IV infusion 1, 4
• Titrate by 2.5 mg/hr every 15 minutes 1, 4
• Maximum dose 15 mg/hr 1, 4
• Target: Reduce MAP by 20-25% within first hour 1, 3
• Then if stable, reduce to 160/100 mmHg over next 2-6 hours 1, 3
• Cautiously normalize over 24-48 hours 1, 3

Alternative: Labetalol IV 1, 2, 3:

• 0.25-0.5 mg/kg IV bolus OR 1
• 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/hr maintenance 2

Critical caveat: Avoid drops >70 mmHg systolic or >25% MAP reduction in first hour—this precipitates cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation. 1, 3

For Acute Coronary Syndrome or Cardiogenic Pulmonary Edema:

Nitroglycerin IV 1, 2, 3:

• Start 5-10 mcg/min IV infusion 2
• Titrate by 5-10 mcg/min every 5-10 minutes 2
• Target: SBP <140 mmHg immediately 1, 3
• Add furosemide 40-80 mg IV for pulmonary edema 1

For Acute Aortic Dissection:

Esmolol PLUS nitroprusside or nitroglycerin 1, 3:

• Target: SBP <120 mmHg AND heart rate <60 bpm immediately 1, 3
• Esmolol: 500 mcg/kg IV bolus over 1 minute, then 50-200 mcg/kg/min infusion 1
• PLUS Nitroprusside: 0.25-10 mcg/kg/min IV infusion 2
• Must control heart rate FIRST before lowering BP 1

For Acute Ischemic Stroke:

Only if BP >220/120 mmHg 1, 3:

• Nicardipine or labetalol (same dosing as above) 1
• Target: Reduce MAP by 15% over 1 hour 1
• If thrombolytic candidate and BP >185/110 mmHg: Reduce MAP by 15% over 1 hour 1
• Critical: Do NOT lower BP if <220/120 mmHg in first 5-7 days unless receiving thrombolytics 1, 2

For Acute Hemorrhagic Stroke:

If SBP ≥220 mmHg 1, 2:

• Nicardipine or labetalol 1
• Target: Reduce SBP to 140-180 mmHg immediately (within 6 hours) 1, 2

For Eclampsia/Severe Preeclampsia:

Labetalol IV or Hydralazine IV 1:

• Target: SBP <160 mmHg and DBP <105 mmHg immediately 1
• Labetalol: 20 mg IV bolus, then 40-80 mg every 10 minutes (max 300 mg) 1
• Alternative: Hydralazine 5-10 mg IV every 20 minutes 5

For Sympathetic Crisis (Cocaine, Amphetamines):

Benzodiazepines FIRST, then phentolamine 1:

• Lorazepam 2-4 mg IV prior to antihypertensive therapy 1
• If additional BP control needed: Phentolamine 5-15 mg IV bolus 1
• Alternatives: Nicardipine or nitroprusside 1
• Avoid beta-blockers alone (can worsen hypertension via unopposed alpha stimulation) 1

For Pheochromocytoma:

Phentolamine (alpha-blocker first) 1:

• Phentolamine 5-15 mg IV bolus 1
• Only add beta-blocker AFTER alpha-blockade established 1
• Alternatives: Urapidil or nitroprusside 1

Transition to Oral Therapy

Once BP stabilized for 24-48 hours 3:

• Start oral antihypertensive combination therapy 3
• Continue IV therapy for 1 hour after first oral dose 4
• Gradually taper IV medications 3

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Hypertensive Urgency Orders (BP >180/120 mmHg WITHOUT Target Organ Damage)

Hypertensive urgency does NOT require hospital admission or IV medications—manage with oral agents and outpatient follow-up. 1, 2, 3

Oral Medication Orders

First-Line Oral Agents:

Captopril 25 mg PO 3, 6:

• Give 25 mg PO once 6
• Recheck BP in 1-2 hours 3
• If inadequate response, may repeat dose 6
• Target: Reduce BP by no more than 25% over 24-48 hours 3

Alternative: Labetalol 200-400 mg PO 3:

• Give 200 mg PO once 3
• Recheck BP in 1-2 hours 3

Alternative: Long-acting nifedipine 30-60 mg PO 3:

• Extended-release formulation only 3
• Never use immediate-release nifedipine (causes unpredictable precipitous drops and reflex tachycardia) 2, 5

Discharge Planning

• Follow-up within 1 week to adjust therapy 3
• Prescribe ongoing oral antihypertensive regimen 3:
  • ACE inhibitor or ARB (e.g., lisinopril 10-20 mg daily) 7
  • PLUS calcium channel blocker (e.g., amlodipine 5-10 mg daily) 7
  • PLUS thiazide diuretic if needed (e.g., chlorthalidone 12.5-25 mg daily) 7
• Target BP: <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 3, 7

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Chronic Hypertension Management Orders (Outpatient)

Initial Therapy

Start combination therapy with two agents from different classes 7:

Preferred First-Line Combinations:

ACE inhibitor or ARB PLUS calcium channel blocker 7:

• Lisinopril 10 mg + amlodipine 5 mg daily OR 7
• Losartan 50 mg + amlodipine 5 mg daily 7

Alternative: ACE inhibitor or ARB PLUS thiazide diuretic 7:

• Lisinopril 10 mg + chlorthalidone 12.5 mg daily OR 7
• Losartan 50 mg + hydrochlorothiazide 12.5 mg daily 7

Titration Strategy

• Titrate to full doses of both agents before adding third drug 3
• If BP remains uncontrolled, add third agent from remaining class 7
• Target BP: <130/80 mmHg for adults <65 years; SBP <130 mmHg for adults ≥65 years 7

Lifestyle Modifications (Additive to Medications)

• Weight loss if overweight (each 1 kg loss reduces SBP by ~1 mmHg) 7
• Dietary sodium restriction to <2 g/day (reduces SBP by 5-6 mmHg) 7
• DASH diet (reduces SBP by 11 mmHg) 7
• Physical activity 150 min/week moderate intensity (reduces SBP by 5-8 mmHg) 7
• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 7

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Post-Emergency Follow-Up Orders

Within 1 Month After Hypertensive Emergency:

• Screen for secondary hypertension (present in 20-40% of malignant hypertension cases) 1, 3:

  • Plasma aldosterone/renin ratio (primary aldosteronism) 3
  • 24-hour urine metanephrines (pheochromocytoma) 3
  • Renal artery duplex ultrasound (renovascular disease) 3
  • Sleep study if obstructive sleep apnea suspected 3

• Assess for residual target organ damage 1:

  • Repeat creatinine, urinalysis 1
  • Echocardiogram (assess LV function, hypertrophy) 1
  • Fundoscopy (monitor retinopathy resolution) 1

• Monthly follow-up until BP controlled and organ damage regressed 1

Long-Term Management:

• Simplify antihypertensive regimen to improve adherence 1
• Consider single-pill combination therapy 1
• Address medication non-adherence (most common trigger for recurrent emergencies) 2
• Target SBP 120-129 mmHg for most adults to reduce cardiovascular risk 3

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Critical Pitfalls to Avoid

• Never lower BP to "normal" acutely in hypertensive emergency—patients with chronic hypertension have altered cerebral autoregulation and cannot tolerate acute normalization 1, 2, 3
• Never use immediate-release nifedipine—causes unpredictable precipitous drops and reflex tachycardia 2, 5
• Never treat asymptomatic elevated BP in hospitalized patients aggressively—observational data suggests intensive inpatient BP treatment may worsen outcomes including AKI and stroke 3
• Never use beta-blockers alone in cocaine/amphetamine toxicity—causes unopposed alpha stimulation and worsening hypertension 1
• Never use beta-blockers before alpha-blockade in pheochromocytoma—accelerates hypertension 1
• Never lower BP in acute ischemic stroke unless >220/120 mmHg (or >185/110 mmHg if thrombolytic candidate)—premature lowering worsens cerebral ischemia 1, 2
• Never delay treatment while awaiting "confirmatory" BP readings in true hypertensive emergency—presence of target organ damage mandates immediate intervention 2, 3