Management of Hypertension with Chills in a 50-Year-Old Male
This patient requires urgent evaluation for infection or other acute illness causing chills before addressing the blood pressure, as chills suggest an underlying acute process that may be driving the hypertensive response and could represent a medical emergency.
Immediate Assessment Priority
The presence of chills is a red flag that must be evaluated immediately, as this suggests:
- Infectious process (sepsis, pneumonia, urinary tract infection, endocarditis) 1
- Acute illness that may be causing secondary hypertension 2
- Potential hypertensive emergency if end-organ damage is present 3, 1
Perform targeted evaluation for acute end-organ damage including assessment for severe headache, visual disturbances, chest pain, dyspnea, altered mental status, or focal neurological deficits 4. If any of these are present alongside BP ≥180/110 mmHg, this constitutes a hypertensive emergency requiring immediate intervention 1.
Blood Pressure Classification and Management
At 150/90 mmHg, this patient has Grade 1 hypertension (BP 140-159/90-99 mmHg) 3.
If No Acute End-Organ Damage Present:
Do NOT rapidly lower blood pressure in the emergency setting - this is asymptomatic hypertension that does not require acute BP reduction and may be harmful 3. The 2006 Annals of Emergency Medicine guidelines explicitly state that initiating treatment for asymptomatic hypertension in the ED is not necessary when patients have follow-up, and rapidly lowering BP in asymptomatic patients is unnecessary and may be harmful 3.
Outpatient Management Approach:
Initiate combination pharmacological therapy as recommended by the 2024 ESC guidelines, since confirmed hypertension (≥140/90 mmHg) warrants prompt treatment regardless of cardiovascular risk 3.
Preferred initial regimen:
- RAS blocker (ACE inhibitor or ARB) + calcium channel blocker (CCB) as a fixed-dose single-pill combination 3
- Alternative: RAS blocker + thiazide/thiazide-like diuretic 3
Target blood pressure: 120-129 mmHg systolic if well tolerated, with minimum target <140/90 mmHg 3. Achieve control within 3 months of treatment initiation 3.
Critical Workup for Chills
Obtain immediately:
- Temperature, complete vital signs
- Complete blood count with differential
- Blood cultures if febrile
- Urinalysis and urine culture
- Chest X-ray
- Basic metabolic panel, creatinine, eGFR 4
- Consider additional infectious workup based on clinical presentation
Follow-Up Timeline
- Reassess within 1 week given the BP elevation and acute symptoms 4
- Check serum creatinine, eGFR, and potassium at 1-4 weeks after initiating RAS blocker therapy 4
- Monthly visits until BP controlled 3
Lifestyle Modifications (Concurrent with Pharmacotherapy)
Implement immediately as these can reduce BP by 5-20 mmHg 4:
- Sodium restriction to <2g/day 4
- Moderate-intensity aerobic exercise ≥150 minutes/week 4
- Weight loss if BMI >25 kg/m² 4
- Limit alcohol to <100g/week 4
- Mediterranean or DASH diet 4
Key Pitfall to Avoid
Do not treat the BP number in isolation - the chills indicate a potentially serious underlying condition that requires diagnosis and treatment. Approximately one-third of patients with diastolic BP >95 mmHg normalize before follow-up 3, and aggressive acute BP lowering without addressing the underlying cause could mask a serious infection or worsen outcomes.