How should a patient with severe hypertension (blood pressure of 210/90 mmHg) be managed?

Management of Blood Pressure 210/90 mmHg

Immediate Assessment Priority

This patient requires urgent assessment for acute target organ damage to differentiate between hypertensive emergency (requiring ICU admission and IV therapy) versus hypertensive urgency (manageable with oral medications outpatient). 1, 2

The critical distinction is not the blood pressure number itself, but whether acute organ damage is present. 3, 1

Systematic Evaluation for Target Organ Damage

Perform focused assessment within minutes for: 1, 2

Neurologic Damage

• Altered mental status, somnolence, lethargy 1
• Headache with vomiting, visual disturbances 1
• Seizures or focal neurological deficits 1

Cardiac Damage

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

Vascular Damage

• Symptoms suggesting aortic dissection (tearing chest/back pain) 1

Renal Damage

• Acute deterioration in renal function 1
• Oliguria or signs of acute kidney injury 1

Ophthalmologic Damage

• Fundoscopy for bilateral retinal hemorrhages, cotton wool spots, or papilledema 1
• Note: Isolated subconjunctival hemorrhage is NOT target organ damage 1

Essential Laboratory Tests

• Complete blood count (hemoglobin, platelets) for microangiopathic hemolytic anemia 1
• Creatinine, 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

Management Algorithm

IF Target Organ Damage Present = Hypertensive Emergency

Immediate ICU admission with continuous arterial line monitoring and parenteral therapy. 3, 1, 2

Blood Pressure Reduction Strategy

• Reduce mean arterial pressure by 20-25% within the first hour (NOT to normal) 3, 1, 2
• Then if stable, reduce to 160/100 mmHg over 2-6 hours 3, 1
• Finally, cautiously normalize over 24-48 hours 3, 1
• Avoid excessive drops >70 mmHg systolic as this precipitates cerebral, renal, or coronary ischemia 3, 1

The rationale: Patients with chronic hypertension have altered autoregulation—acute normalization causes organ hypoperfusion. 3, 1

First-Line IV Medications

• Nicardipine: 5 mg/hr IV, titrate by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr 1
  • Advantages: Predictable titration, maintains cerebral blood flow 1
• Labetalol: 10-20 mg IV bolus over 1-2 minutes, repeat/double every 10 minutes, maximum cumulative 300 mg 1
  • Alternative: 2-8 mg/min continuous infusion 3, 1
  • Preferred for encephalopathy, eclampsia, aortic dissection 1
• Clevidipine: 1-2 mg/hr, double every 90 seconds until approaching target, maximum 32 mg/hr 1

Medications to Avoid

• Immediate-release nifedipine: Causes unpredictable precipitous drops and reflex tachycardia 1
• Hydralazine: Unpredictable response and prolonged duration 1
• Sodium nitroprusside: Use only as last resort due to cyanide toxicity risk 1

IF NO Target Organ Damage = Hypertensive Urgency

Manage with oral antihypertensives and outpatient follow-up within 2-4 weeks—hospital admission NOT required. 3, 1

Oral Medication Approach

• Start combination therapy with RAS blocker (ACE inhibitor or ARB) plus dihydropyridine calcium channel blocker 3
• Examples: Lisinopril 10 mg plus amlodipine 5 mg daily 4, 5
• If BP remains uncontrolled, add thiazide/thiazide-like diuretic as third agent 3
• Target BP <130/80 mmHg, achieve within 3 months 3

Blood Pressure Reduction Strategy

• Reduce BP gradually over 24-48 hours, NOT acutely 1
• Rapid BP lowering in asymptomatic patients may cause harm through hypotension-related complications 1
• Up to one-third of patients normalize before follow-up 1

Critical Pitfalls to Avoid

• Do not admit patients with asymptomatic hypertension without acute target organ damage 1
• Do not use IV medications for hypertensive urgency—oral therapy is appropriate 1
• Do not rapidly lower BP to "normal" in hypertensive emergency—this causes ischemic complications 3, 1
• Do not assume absence of symptoms means no organ damage—systematic evaluation is mandatory 1
• Do not confuse isolated subconjunctival hemorrhage with malignant hypertensive retinopathy (requires bilateral findings) 1

Post-Stabilization Management

After acute management: 1, 2

• Screen for secondary hypertension causes (present in 20-40% of malignant hypertension) 1, 2
• Address medication non-adherence (most common trigger) 1
• Transition to oral combination therapy with RAS blocker, calcium channel blocker, and diuretic 3, 2
• Frequent follow-up (at least monthly) until target BP reached 1

Without treatment, hypertensive emergencies carry >79% 1-year mortality. 1