What are the treatment options for a patient with severely elevated blood pressure (hypertension), presenting with nervousness, but no other symptoms?

Hypertensive Urgency Management

For a patient with blood pressure 200/120 mmHg who is asymptomatic except for nervousness, this represents a hypertensive urgency—not an emergency—and should be managed with oral antihypertensive medications and outpatient follow-up, not hospitalization or IV therapy. 1

Critical First Step: Rule Out Target Organ Damage

The absolute blood pressure number does not define a hypertensive emergency—the presence or absence of acute target organ damage is what matters. 1, 2

Perform a focused assessment within minutes to identify any signs of acute organ damage: 1

• Neurologic: Altered mental status, severe headache with vomiting, visual disturbances, seizures, focal deficits, or loss of consciousness 1, 3
• Cardiac: Chest pain, acute myocardial infarction, acute heart failure with pulmonary edema 1
• Vascular: Signs of aortic dissection (tearing chest/back pain, blood pressure differential between arms) 1
• Renal: Acute kidney injury (check creatinine, urinalysis for proteinuria/hematuria) 1
• Ophthalmologic: Fundoscopy for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 1, 2

In your case: nervousness alone is NOT target organ damage. 1 Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and anxiety/nervousness commonly causes transient blood pressure elevations that resolve when the patient calms down. 1

Why This is NOT a Hypertensive Emergency

• No acute target organ damage present = hypertensive urgency, not emergency 1, 4
• Nervousness is a non-specific symptom that does not indicate acute brain, heart, kidney, or vascular injury 1, 5
• The rate of blood pressure rise matters more than the absolute value—patients with chronic hypertension often tolerate higher pressures 1, 3

Appropriate Management for Hypertensive Urgency

Do NOT Hospitalize or Use IV Medications

Patients with hypertensive urgency do not require hospital admission or IV medications. 1 Severely hypertensive patients without acute organ damage should be managed with oral antihypertensive therapy and outpatient follow-up. 1, 4

Blood Pressure Reduction Timeline

Reduce blood pressure gradually over 24-48 hours, NOT within minutes or hours. 1, 5, 4 Rapid blood pressure lowering in asymptomatic patients may be harmful and can cause cerebral, renal, or coronary ischemia due to altered autoregulation in patients with chronic hypertension. 1, 5

Oral Medication Selection

Initiate or adjust oral antihypertensive therapy: 1

• First-line options: ACE inhibitor/ARB, calcium channel blocker, or thiazide/thiazide-like diuretic 1, 6
• Avoid immediate-release nifedipine due to unpredictable precipitous drops and reflex tachycardia 1
• Target blood pressure: <130/80 mmHg for most adults <65 years 1, 6

Follow-Up Requirements

Arrange outpatient follow-up within 2-4 weeks to assess response to therapy and ensure blood pressure control. 1 If adequate follow-up cannot be ensured, consider observation in an outpatient emergency service with gradual blood pressure reduction over 4-6 hours. 5

Critical Pitfalls to Avoid

• Do not treat the blood pressure number alone without assessing for true hypertensive emergency 1
• Do not use IV medications for hypertensive urgency—oral therapy is appropriate 1
• Do not rapidly lower blood pressure in asymptomatic patients—this may cause harm through hypotension-related complications 1, 5
• Do not admit to hospital unless target organ damage is present or adequate outpatient follow-up cannot be arranged 1, 4

Address the Underlying Cause

Evaluate for common triggers: 2

• Medication non-compliance (most common cause) 1, 2
• Inadequate antihypertensive therapy 5
• Use of NSAIDs, steroids, sympathomimetics, or recreational drugs (cocaine, methamphetamine) 1, 2
• Secondary hypertension causes (consider screening after stabilization) 1, 2