What is the management approach for an adult patient with no known medical history presenting with severe diastolic hypertension and systolic hypotension?

Critical Assessment: This is NOT a Hypertensive Emergency

This blood pressure reading of 99/160 mmHg (systolic 99, diastolic 160) is physiologically implausible and most likely represents a measurement error, reversed cuff placement, or equipment malfunction—you must immediately remeasure the blood pressure correctly before any clinical decision-making. 1

Immediate Actions Required

1. Verify the Blood Pressure Reading

• Remeasure blood pressure using proper technique with the patient seated, back supported, feet flat on floor, arm at heart level, after 5 minutes of rest 2
• Confirm cuff size is appropriate for the patient's arm circumference, as incorrect cuff sizing is a common source of error 2
• Check for reversed systolic/diastolic readings—if the actual reading is 160/99 mmHg, this changes the entire clinical approach 1
• Obtain blood pressure in both arms to rule out measurement artifact or peripheral vascular disease 2

2. Assess for Target Organ Damage (If BP Truly Elevated)

Assuming the corrected reading shows severely elevated blood pressure (≥180/120 mmHg), immediately assess for acute target organ damage to differentiate hypertensive emergency from urgency 1, 3:

Neurologic assessment:

• Altered mental status, confusion, somnolence, or lethargy suggesting hypertensive encephalopathy 1, 3
• Severe headache with vomiting (multiple episodes) 1
• Visual disturbances, vision loss, or focal neurological deficits 1, 3
• Seizure activity 1

Cardiac assessment:

• Chest pain suggesting acute myocardial ischemia or infarction 1, 3
• Acute dyspnea or pulmonary edema 1
• Signs of acute heart failure 1, 3

Vascular assessment:

• Symptoms of aortic dissection (tearing chest/back pain, pulse differential) 1, 3

Renal assessment:

• Acute oliguria or signs of acute kidney injury 1, 3

Ophthalmologic assessment:

• Fundoscopic exam for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 1, 3

Management Algorithm Based on Corrected Reading

If Blood Pressure is ≥180/120 mmHg WITH Acute Target Organ Damage (Hypertensive Emergency)

Immediate ICU admission is mandatory (Class I recommendation, Level B-NR) 1, 3:

• Place arterial line for continuous beat-to-beat BP monitoring 1
• Initiate IV nicardipine as first-line agent: 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr 1, 3
• Alternative: IV labetalol 10-20 mg IV bolus over 1-2 minutes, repeat/double every 10 minutes, maximum cumulative 300 mg 1, 3
• Target: Reduce mean arterial pressure by 20-25% within the first hour, then if stable reduce to 160/100 mmHg over 2-6 hours, then cautiously normalize over 24-48 hours 1, 3
• Critical: Avoid excessive drops >70 mmHg systolic as this precipitates cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation 1, 3

Essential laboratory tests:

• Complete blood count (hemoglobin, platelets) 1
• Renal function panel (creatinine, BUN, electrolytes) 1
• Lactate dehydrogenase and haptoglobin (to detect hemolysis) 1
• Urinalysis with microscopy 1
• Troponin and ECG 1

If Blood Pressure is ≥180/120 mmHg WITHOUT Acute Target Organ Damage (Hypertensive Urgency)

Do NOT admit to hospital or initiate IV medications 3:

• Initiate or adjust oral antihypertensive therapy: ACE inhibitor or ARB plus calcium channel blocker (or thiazide/thiazide-like diuretic for Black patients) 3
• Target BP <130/80 mmHg over weeks to months, NOT hours 3
• Arrange urgent outpatient follow-up within 24-48 hours with primary physician for gradual BP reduction 3
• Up to one-third of patients with elevated BP normalize spontaneously before follow-up, and rapid BP lowering in asymptomatic patients is unnecessary and may precipitate renal, cerebral, or coronary ischemia 3

If Blood Pressure is <180/120 mmHg (e.g., 160/99 mmHg)

• This does NOT constitute a hypertensive emergency or urgency 2, 3
• Initiate or adjust oral antihypertensive therapy with outpatient follow-up within 2-4 weeks 3
• No hospital admission or IV medications required 3

Critical Pitfalls to Avoid

• Never treat a blood pressure number alone without assessing for acute target organ damage—the presence or absence of acute organ damage is the sole determining factor for emergency management, not the BP number itself 1, 3
• Never use immediate-release nifedipine due to unpredictable precipitous drops and reflex tachycardia 1
• Never rapidly normalize BP in patients with chronic hypertension—they have altered cerebral autoregulation and cannot tolerate acute normalization 1, 3
• Never assume a single elevated BP reading represents true hypertension—up to 25% of patients do not fill their initial prescription, and many normalize spontaneously 2, 3
• Never initiate IV therapy for hypertensive urgency—this is inappropriate and potentially harmful 3

Special Considerations

• If the patient has chronic hypertension, they may tolerate higher BP levels than previously normotensive individuals, and the rate of BP rise may be more important than the absolute value 1
• Screen for secondary hypertension causes after stabilization, as 20-40% of malignant hypertension cases have secondary causes including renal artery stenosis, pheochromocytoma, or primary aldosteronism 1
• Assess for medication non-compliance, the most common trigger for hypertensive emergencies 1
• Evaluate for interfering substances including NSAIDs, stimulants, cocaine, amphetamines, and oral contraceptives 2, 1