What is the best course of action for a patient with a history of hypertension, presenting with tachycardia, elevated blood pressure, shoulder pain, and burping?

Immediate Assessment and Management

This patient requires urgent evaluation to differentiate between a hypertensive urgency and a hypertensive emergency, with the key distinction being the presence or absence of acute target organ damage. 1, 2

Critical First Step: Rule Out Hypertensive Emergency

The blood pressure of 124/94 mmHg with heart rate of 122 bpm, combined with shoulder pain and burping, demands immediate assessment for acute target organ damage. 1, 2

Key clinical features to evaluate immediately:

• Cardiac assessment: The shoulder pain could represent coronary ischemia (angina or acute myocardial infarction). Obtain an ECG immediately and check troponin levels. 1, 3
• Neurological examination: Assess for signs of hypertensive encephalopathy, stroke, or altered mental status. 1, 2
• Cardiovascular signs: Evaluate for acute heart failure or pulmonary edema (dyspnea, rales, elevated JVP). 1, 3
• Renal function: Check creatinine and urinalysis for acute kidney injury or thrombotic microangiopathy. 1, 4

The tachycardia (HR 122) is concerning and may indicate:

• Acute coronary syndrome (especially with shoulder pain) 5
• Sympathetic activation from pain or anxiety 3
• Underlying arrhythmia (atrial fibrillation is common in hypertensive patients) 1, 5

Management Based on Findings

If Hypertensive Emergency (Target Organ Damage Present):

Immediate hospitalization to an intensive care unit with continuous BP monitoring and IV antihypertensive therapy is required. 1, 3

• Target BP reduction: Reduce mean arterial pressure by 20-25% within the first hour, then to 160/100-110 mmHg over the next 2-6 hours. 1, 4
• First-line IV agents: Labetalol or nicardipine are preferred for most hypertensive emergencies. 1
• Avoid excessive BP lowering: Precipitous drops can cause renal, cerebral, or coronary ischemia. 1

Specific considerations if coronary ischemia confirmed:

• Labetalol is first-line for acute coronary syndrome with hypertension. 1
• Nitroglycerin (5-100 μg/min IV) is indicated for coronary ischemia. 1
• Beta-blockers help control both heart rate and BP in this setting. 1

If Hypertensive Urgency (No Target Organ Damage):

Oral antihypertensive medication with gradual BP reduction over 24-48 hours is appropriate; aggressive acute lowering should be avoided. 1, 4

• Observation period: Monitor for at least 2 hours after initiating or adjusting oral medication to evaluate efficacy and safety. 1
• Oral agents: Captopril, labetalol, or extended-release nifedipine can be used (avoid short-acting nifedipine due to risk of precipitous BP drops). 1, 4
• Outpatient follow-up: Arrange close follow-up within days to reassess BP control and adjust chronic therapy. 1, 6

Long-Term Hypertension Management

For chronic BP control, combination therapy with a RAS blocker (ACE inhibitor or ARB) plus a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic is recommended as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

• Target BP: Aim for systolic BP 120-129 mmHg if well tolerated to reduce cardiovascular risk. 1
• Single-pill combinations: Fixed-dose combinations improve adherence and are preferred. 1
• Three-drug combination: If BP remains uncontrolled on two drugs, escalate to RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic. 1

Critical Pitfalls to Avoid

• Do not use short-acting nifedipine: This can cause dangerous precipitous BP drops and is no longer acceptable for hypertensive crises. 1
• Do not aggressively lower BP in urgencies: Rapid reduction without target organ damage can precipitate ischemic complications. 1, 4
• Do not miss secondary causes: The tachycardia and symptoms warrant evaluation for pheochromocytoma, thyroid disease, or other secondary causes, especially if BP proves difficult to control. 1
• Do not overlook medication non-adherence: This is the most common cause of resistant hypertension and should be addressed directly. 1

Addressing the Tachycardia

Beta-blockers are indicated when there are compelling reasons such as angina, post-MI, heart failure with reduced ejection fraction, or for heart rate control. 1

• If coronary ischemia is confirmed, beta-blockade is essential. 1
• Hypertension is the most important risk factor for atrial fibrillation; obtain ECG to rule out arrhythmia. 1, 5
• Labetalol provides both alpha and beta blockade, making it ideal if both BP and heart rate control are needed. 1