Should an adult patient with no prior history of hypertension and a blood pressure reading of severe hypertension (218/104) be referred to the hospital immediately?

Management of Blood Pressure 218/104 mmHg

This patient does NOT need to go to the hospital unless they have evidence of acute target organ damage—the critical first step is immediately assessing for symptoms or signs of organ injury, not treating the blood pressure number alone. 1, 2

Immediate Assessment Required

The distinction between hypertensive emergency and hypertensive urgency determines whether hospital admission is necessary. The presence or absence of acute target organ damage is the sole determining factor for emergency referral, not the blood pressure number itself. 1

Assess for Target Organ Damage (Takes Minutes)

Perform a focused evaluation looking for:

Neurologic damage: 1, 2

• Altered mental status, confusion, or somnolence
• Severe headache with vomiting
• Visual disturbances or vision loss
• Seizures or focal neurological deficits

Cardiac damage: 1, 2

• Chest pain suggesting acute myocardial ischemia
• Acute dyspnea or pulmonary edema
• Signs of acute heart failure

Vascular damage: 1

• Severe tearing chest or back pain (aortic dissection)

Renal damage: 1, 2

• Oliguria or acute renal failure symptoms

Ophthalmologic damage: 1

• Perform fundoscopy looking for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension)

If Target Organ Damage Present: HOSPITAL ADMISSION REQUIRED

Admit immediately to ICU for continuous monitoring and IV antihypertensive therapy. 1

Treatment Approach for Hypertensive Emergency

• Reduce mean arterial pressure by 20-25% within the first hour (not to normal), then if stable reduce to 160/100 mmHg over 2-6 hours, then cautiously normalize over 24-48 hours 1, 3
• Avoid excessive drops >70 mmHg systolic as this can precipitate cerebral, renal, or coronary ischemia 1
• Patients with chronic hypertension have altered autoregulation and cannot tolerate acute normalization 1, 4

First-Line IV Medications

Nicardipine: 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr 1, 5

• Preferred for most hypertensive emergencies
• Maintains cerebral blood flow
• Predictable titration

Labetalol: 10-20 mg IV bolus over 1-2 minutes, repeat/double every 10 minutes, maximum cumulative 300 mg 1

• Preferred for encephalopathy, eclampsia, aortic dissection
• Controls both heart rate and blood pressure

If NO Target Organ Damage: NO HOSPITAL ADMISSION

This represents hypertensive urgency and should be managed with oral medications and outpatient follow-up—hospital admission is not indicated and rapid BP lowering may be harmful. 6, 2

Management of Hypertensive Urgency

• Do NOT initiate IV medications or rapid BP reduction 2
• Up to one-third of patients with elevated BP normalize spontaneously before follow-up 6, 2
• Rapid BP lowering in asymptomatic patients is unnecessary and may precipitate renal, cerebral, or coronary ischemia 2

Outpatient Treatment Plan

Initiate or adjust oral antihypertensive therapy: 2

• Start low-dose ACE inhibitor or ARB plus calcium channel blocker
• Add thiazide diuretic as third-line if needed
• Target BP <130/80 mmHg over weeks to months, not hours

Arrange urgent outpatient follow-up within 24-48 hours with primary physician for gradual BP reduction 2

Critical Pitfalls to Avoid

• Do not admit patients with asymptomatic hypertension without evidence of acute target organ damage 2
• Do not use short-acting nifedipine due to unpredictable precipitous drops and reflex tachycardia 1, 3
• Do not treat the BP number alone—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 1
• Do not rapidly lower BP in hypertensive urgency—this may cause harm through hypotension-related complications 2

Common Clinical Scenario

Most patients presenting with BP 218/104 who are asymptomatic or have only non-specific symptoms (headache, anxiety) have hypertensive urgency, not emergency, and do not require hospitalization. 6, 2 The rate of BP rise may be more important than the absolute value, and patients with chronic hypertension often tolerate higher pressures than previously normotensive individuals. 1