What is the best approach to manage a 75-year-old female patient with severely elevated blood pressure (hypertension) and a complaint of heaviness of head?

Immediate Management of Severe Hypertension with Headache in a 75-Year-Old Woman

This patient requires urgent evaluation to differentiate between a hypertensive emergency (requiring immediate IV treatment) versus severe hypertension with headache (which may be managed more conservatively), followed by appropriate blood pressure reduction based on that assessment. 1

Initial Assessment Priority

First, exclude hypertensive emergency by evaluating for acute end-organ damage:

• Neurologic assessment: Check for altered mental status, focal neurologic deficits, seizures, or signs of hypertensive encephalopathy or intracerebral hemorrhage 1
• Cardiac evaluation: Assess for chest pain, acute pulmonary edema, acute myocardial infarction, or acute heart failure 1, 2
• Fundoscopic examination: Recommended when BP >180/110 mmHg to evaluate for papilledema, hemorrhages, or exudates indicating malignant hypertension 1
• Renal function: Check for acute kidney injury or hematuria 1, 2

Diagnostic Workup

Obtain immediately:

• 12-lead ECG to assess for acute cardiac ischemia or left ventricular hypertrophy 1
• Serum creatinine and eGFR 1
• Urinalysis with albumin-to-creatinine ratio 1
• Serum electrolytes 1

Treatment Algorithm

If Hypertensive Emergency is Present (Evidence of Acute Organ Damage):

Admit to intensive care unit for continuous BP monitoring and parenteral therapy. 1, 2

Target BP reduction: Reduce mean arterial pressure by no more than 25% within the first hour, then if stable, to 160/100-110 mmHg within the next 2-6 hours. 1

Preferred IV agent - Nicardipine:

• Start at 5 mg/hr IV infusion 3
• Titrate by 2.5 mg/hr every 15 minutes (or every 5 minutes for more rapid control) up to maximum 15 mg/hr 3
• Average time to therapeutic response is approximately 12-77 minutes depending on clinical scenario 3
• Change infusion site every 12 hours if using peripheral vein 3

Alternative IV agents include: labetalol, esmolol, fenoldopam, or clevidipine 2

Avoid: Immediate-release nifedipine (risk of precipitous BP drop causing ischemia), hydralazine 1, 2

If No Acute Organ Damage (Hypertensive Urgency):

Consider that "heaviness of head" may represent pain/discomfort causing reactive BP elevation rather than true hypertensive urgency. 4

Management approach:

• Provide symptomatic relief for headache with appropriate analgesia 4
• Observe BP response after pain control - many patients will have BP normalization once discomfort is relieved 4
• Do NOT initiate long-acting antihypertensive medications based solely on BP readings during acute symptoms 4

If BP remains ≥160/100 mmHg after symptom control:

• Confirm elevation with repeated measurements within 1 month, preferably using home BP monitoring or ambulatory BP monitoring 1
• Can consider oral antihypertensive therapy for outpatient management rather than IV therapy 2, 5

Age-Specific Considerations for This 75-Year-Old Patient

Before initiating or intensifying BP medications:

• Test for orthostatic hypotension (measure BP after 5 minutes sitting/lying, then at 1 and/or 3 minutes after standing) 1
• Assess frailty status 1

BP treatment targets for elderly patients:

• Target systolic BP 120-129 mmHg if well tolerated 1
• If poorly tolerated, use "as low as reasonably achievable" (ALARA) principle 1
• Maintain lifelong BP-lowering treatment even beyond age 85 if well tolerated 1

Common Pitfalls to Avoid

Do not over-treat:

• Excessive rapid BP reduction can precipitate renal, cerebral, or coronary ischemia 1
• Starting long-term medications during acute pain/distress may lead to unnecessary medication burden 4

Do not under-treat:

• This BP of 200/100 mmHg requires confirmation and eventual treatment, but timing depends on presence of acute organ damage 1
• Therapeutic inertia is common and should be avoided 6

Follow-Up Plan

If managed as urgency without IV therapy:

• Schedule follow-up BP measurement within 1-4 weeks after symptom resolution 4
• Confirm persistent hypertension with out-of-office BP monitoring (home or ambulatory) 1
• If confirmed hypertension, initiate standard guideline-based treatment with lifestyle modifications and pharmacotherapy targeting BP <140/90 mmHg minimum 1

Screen for secondary hypertension if indicated by clinical presentation, though comprehensive screening is primarily recommended for younger patients (<40 years) 1