What should I do for a patient with severely elevated blood pressure (hypertension) of 240/120mmHg, with no known medical history?

Immediate Management of Blood Pressure 240/120 mmHg

You must immediately assess for acute target organ damage to determine if this is a hypertensive emergency requiring ICU admission with IV medications, or a hypertensive urgency manageable with oral agents and outpatient follow-up. 1

Critical First Step: Assess for Target Organ Damage

Perform a rapid focused assessment within minutes to identify signs of acute organ injury: 1

Neurologic assessment:

• Altered mental status, confusion, or memory problems (hypertensive encephalopathy) 1, 2
• Severe headache with vomiting 1, 2
• Visual disturbances or vision loss 1, 2
• Focal weakness, facial drooping, or speech difficulty (stroke) 1, 2
• Seizures or loss of consciousness 1, 2

Cardiac assessment:

• Chest pain (acute MI, unstable angina, aortic dissection) 1, 2
• Shortness of breath or orthopnea (acute heart failure/pulmonary edema) 1, 2

Other critical signs:

• Fundoscopic exam for retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 1

If Target Organ Damage Present: HYPERTENSIVE EMERGENCY

Immediate actions required: 1

1. Admit to ICU immediately (Class I recommendation) 1

2. Start IV nicardipine as first-line agent:

   • Initial dose: 5 mg/hr IV infusion 1, 3
   • Titrate by 2.5 mg/hr every 15 minutes 1, 3
   • Maximum dose: 15 mg/hr 1, 3
   • Nicardipine maintains cerebral blood flow and allows precise titration 1

3. Alternative first-line: IV labetalol

   • 0.25-0.5 mg/kg IV bolus OR 2-4 mg/min continuous infusion 1
   • Particularly effective for renal involvement 1
   • Contraindicated in reactive airway disease, COPD, heart block, or decompensated heart failure 1

4. Blood pressure target:

   • Reduce mean arterial pressure by 20-25% within the first hour 1
   • Then if stable, reduce to 160/100 mmHg over 2-6 hours 1
   • Cautiously normalize over 24-48 hours 1
   • Avoid excessive drops >70 mmHg systolic - this precipitates cerebral, renal, or coronary ischemia 1

5. Continuous monitoring:

   • Arterial line for continuous BP monitoring 1
   • Serial neurologic, cardiac, and renal assessments 1

If NO Target Organ Damage: HYPERTENSIVE URGENCY

This patient can be managed without hospitalization: 1, 4

1. Start oral antihypertensive therapy:

   • Low-dose ACE inhibitor or ARB plus dihydropyridine calcium channel blocker 1
   • OR calcium channel blocker plus thiazide diuretic 1
   • Goal: Reduce BP gradually over 24-48 hours, NOT immediately 1, 4

2. Arrange follow-up within 2-4 weeks to assess response 4

3. Target BP: <130/80 mmHg achieved over 3 months 1

Essential Laboratory Tests

Order immediately to assess for occult organ damage: 1

• Complete blood count (hemoglobin, platelets) - assess for microangiopathic hemolytic anemia 1
• Basic metabolic panel (creatinine, sodium, potassium) - evaluate renal function 1
• Urinalysis with microscopy - identify proteinuria or abnormal sediment 1
• Troponin if any chest discomfort - rule out acute MI 1
• ECG - assess for cardiac involvement 1
• LDH and haptoglobin - detect hemolysis in thrombotic microangiopathy 1

Critical Medications to AVOID

• Immediate-release nifedipine - causes unpredictable precipitous drops and reflex tachycardia 1, 5
• Hydralazine as first-line - unpredictable response and prolonged duration 1
• Sodium nitroprusside except as last resort - risk of cyanide toxicity 1, 5

Key Clinical Pitfalls

• The rate of BP rise matters more than the absolute number - patients with chronic hypertension tolerate higher pressures 1, 2
• Do not rapidly normalize BP in chronic hypertension - altered autoregulation causes ischemia 1
• Without treatment, hypertensive emergencies carry 79% one-year mortality 1
• 20-40% of malignant hypertension cases have secondary causes - screen after stabilization 1