How should a patient with severe hypertension (BP 200/100) be managed?

Management of Severe Hypertension (BP 200/100)

Immediate Assessment Priority

The critical first step is determining whether acute target organ damage is present—this distinction between hypertensive emergency versus urgency dictates all subsequent management. 1

Assess for Target Organ Damage (Within Minutes)

Perform focused evaluation for:

• Neurologic damage: Altered mental status, severe headache with vomiting, visual disturbances, seizures, focal deficits, or signs of stroke 1
• Cardiac damage: Chest pain, acute myocardial infarction, acute heart failure with pulmonary edema 1
• Vascular damage: Signs/symptoms of aortic dissection (tearing chest/back pain, pulse differentials) 1
• Renal damage: Oliguria, acute kidney injury, signs of thrombotic microangiopathy 1
• Ophthalmologic damage: Fundoscopy for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 2, 1

Management Algorithm

IF Target Organ Damage Present = HYPERTENSIVE EMERGENCY

Admit immediately to ICU with continuous arterial line BP monitoring and initiate IV antihypertensive therapy. 1

Blood Pressure Target

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

First-Line IV Medications

Nicardipine is the preferred agent for most hypertensive emergencies:

• Start 5 mg/hr IV infusion 1, 3
• Titrate by 2.5 mg/hr every 15 minutes 3
• Maximum 15 mg/hr 3
• Advantages: Predictable titration, maintains cerebral blood flow, does not increase intracranial pressure 1

Labetalol as alternative:

• 10-20 mg IV bolus over 1-2 minutes 1
• Repeat or double dose every 10 minutes 1
• Maximum cumulative dose 300 mg 1
• OR continuous infusion 2-8 mg/min 1
• Preferred for: Encephalopathy, eclampsia, aortic dissection 1
• Contraindications: Reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 1

Essential Laboratory Tests

• Complete blood count (hemoglobin, platelets) for microangiopathic hemolytic anemia 1
• Creatinine, BUN, sodium, potassium for renal function 1
• Lactate dehydrogenase and haptoglobin for hemolysis 1
• Urinalysis for protein and urine sediment 1
• Troponins if chest pain present 1
• ECG 1

Post-Stabilization

• Screen for secondary hypertension (found in 20-40% of malignant hypertension cases) 1
• Transition to oral therapy with RAS blocker + calcium channel blocker + thiazide/thiazide-like diuretic, preferably as single-pill combination 2
• Target systolic BP 120-129 mmHg long-term 2, 1

IF NO Target Organ Damage = HYPERTENSIVE URGENCY

Do NOT admit to hospital. Manage with oral medications and outpatient follow-up. 4, 5

Key Evidence

• Up to one-third of patients with severely elevated BP normalize before follow-up 5
• Rapid BP lowering in asymptomatic patients may be harmful 5
• IV medications are contraindicated in hypertensive urgency 4, 5

Oral Medication Approach

For non-Black patients:

• Start low-dose ACE inhibitor or ARB 1
• Add dihydropyridine calcium channel blocker if needed 1
• Add thiazide/thiazide-like diuretic as third agent 1

For Black patients:

• Start ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1
• Add missing component as third agent 1

Specific oral agents for urgency:

• Captopril (particularly useful with high renin activity; contraindicated in pregnancy and bilateral renal artery stenosis) 5
• Extended-release nifedipine (NOT immediate-release) 4, 5
• Avoid short-acting nifedipine due to risk of rapid, uncontrolled BP falls 5

Blood Pressure Target

• Reduce gradually over 24-48 hours 4
• Target <130/80 mmHg (or <140/90 mmHg in elderly/frail) 1
• Achieve target within 3 months 1

Monitoring

• Observe for at least 2 hours after medication administration 4
• Arrange follow-up within 2-4 weeks 1

Critical Pitfalls to Avoid

• Do not treat the BP number alone without assessing for true target organ damage—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1
• Do not use immediate-release nifedipine—causes unpredictable precipitous drops and reflex tachycardia 1, 6
• Do not rapidly normalize BP in chronic hypertension—patients have altered autoregulation and acute normalization causes ischemic complications 2, 1
• Do not use IV medications for hypertensive urgency—this is inappropriate and potentially harmful 4, 5
• Do not overlook medication non-adherence—the most common trigger for hypertensive crises 1