What is the appropriate management for a patient presenting to the emergency room with hypertension?

Management of Hypertension in the Emergency Room

Admit the patient to the ICU for continuous monitoring and IV antihypertensive therapy if blood pressure is ≥180/120 mmHg WITH acute target organ damage; otherwise, manage as an outpatient with oral medications and follow-up within 2-4 weeks. 1, 2

Critical First Step: Differentiate Emergency from Urgency

The presence or absence of acute target organ damage—not the absolute blood pressure number—determines your entire management approach. 1, 2

Assess for Acute Target Organ Damage

Perform a rapid, focused assessment looking specifically for: 1, 2

Neurologic damage:

• Altered mental status, somnolence, lethargy, confusion 1, 3
• Headache with multiple episodes of vomiting 1, 3
• Visual disturbances, cortical blindness 4, 1
• Seizures or focal neurological deficits 1, 2

Cardiac damage:

• Chest pain suggesting acute myocardial ischemia or infarction 1, 2
• Acute pulmonary edema or heart failure 1, 2

Vascular damage:

• Signs or symptoms of aortic dissection 1, 2

Renal damage:

• Acute deterioration in renal function (check creatinine) 1, 2
• Proteinuria on urinalysis 1

Ophthalmologic damage:

• Bilateral retinal hemorrhages, cotton wool spots, or papilledema on fundoscopy (Grade III-IV retinopathy) 4, 1

Obstetric (if applicable):

• Eclampsia or severe preeclampsia 1, 2

Essential Laboratory Tests

Order immediately: 1

• Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia
• Basic metabolic panel (creatinine, sodium, potassium)
• Lactate dehydrogenase (LDH) and haptoglobin to detect hemolysis
• Urinalysis for protein and urine sediment
• Troponins if chest pain present
• ECG

Management Algorithm

If Target Organ Damage Present = HYPERTENSIVE EMERGENCY

Immediate actions: 1, 2

1. Admit to ICU immediately (Class I recommendation) 1, 2

2. Establish continuous arterial line BP monitoring 1

3. Start IV antihypertensive therapy 1, 2

First-line IV medications: 1, 2

Nicardipine (preferred for most situations):

• Start at 5 mg/hr IV infusion 1, 5
• Titrate by 2.5 mg/hr every 15 minutes 1, 5
• Maximum 15 mg/hr 1, 5
• Advantages: Maintains cerebral blood flow, predictable titration 1
• Must dilute single-dose vials to 0.1 mg/mL concentration 5

Labetalol (preferred for encephalopathy, eclampsia, aortic dissection):

• Initial bolus: 10-20 mg IV over 1-2 minutes 1, 2
• Repeat or double dose every 10 minutes 1
• Maximum cumulative dose: 300 mg 1
• Alternative: continuous infusion at 2-8 mg/min 1
• Contraindications: reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 1

Clevidipine (alternative):

• Start at 1-2 mg/hr 1, 6
• Double every 90 seconds until BP approaches target 1, 6
• Then increase by less than double every 5-10 minutes 1, 6
• Maximum 32 mg/hr 1, 6
• Contraindications: soy/egg allergy, defective lipid metabolism 1

Blood pressure reduction targets: 1, 2

Standard approach (most emergencies):

• First hour: Reduce mean arterial pressure by 20-25% (or SBP by no more than 25%) 1, 2
• Next 2-6 hours: If stable, reduce to 160/100 mmHg 1, 2
• Next 24-48 hours: Cautiously normalize 1, 2

Critical warning: Avoid excessive acute drops >70 mmHg systolic—this precipitates cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation. 1, 2

Condition-specific modifications: 1, 2

• Aortic dissection: Target SBP ≤120 mmHg within 20 minutes; use esmolol plus nitroprusside/nitroglycerin 1
• Acute coronary syndrome: Target SBP <140 mmHg immediately; use nitroglycerin ± labetalol 1
• Acute pulmonary edema: Target SBP <140 mmHg immediately; use nitroglycerin or nitroprusside 1
• Acute ischemic stroke: Avoid BP reduction unless >220/120 mmHg; if treating, reduce MAP by 15% over first hour 1
• Acute hemorrhagic stroke: If SBP ≥220 mmHg, carefully lower to 140-160 mmHg 1
• Eclampsia/preeclampsia: Use hydralazine, labetalol, or nicardipine; absolutely avoid ACE inhibitors, ARBs, and nitroprusside 1

If NO Target Organ Damage = HYPERTENSIVE URGENCY

Do NOT admit to hospital. 1, 2

Management approach: 1, 2

1. Initiate or adjust oral antihypertensive therapy 1, 2

2. Arrange outpatient follow-up within 2-4 weeks 1, 2

3. Reduce BP gradually over 24-48 hours, NOT acutely 1

Oral medication options: 1

For non-Black patients:

• Start low-dose ACE inhibitor or ARB 1
• Add dihydropyridine calcium channel blocker if needed 1
• Add thiazide or thiazide-like diuretic as third-line 1

For Black patients:

• Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1
• Add the missing component as third-line 1

Target BP: <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 1

Critical pitfall: Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and rapid BP lowering in asymptomatic patients may be harmful. 1

Medications to AVOID

• Immediate-release nifedipine: Causes unpredictable precipitous drops, reflex tachycardia, stroke, and death 1, 7
• Hydralazine (as first-line): Unpredictable response and prolonged duration 1
• Sodium nitroprusside (except as last resort): Cyanide toxicity risk with prolonged use (>48-72 hours) or renal insufficiency 1, 7

Post-Stabilization Management

After stabilizing a hypertensive emergency: 1

1. Screen for secondary hypertension causes (found in 20-40% of malignant hypertension): 4, 1

   • Renal artery stenosis
   • Pheochromocytoma
   • Primary aldosteronism
   • Renal parenchymal disease

2. Address medication non-adherence (most common trigger) 1

3. Transition to oral antihypertensive therapy with combination regimen (RAS blockers, calcium channel blockers, diuretics) 1

4. Arrange frequent follow-up (at least monthly) until target BP achieved and organ damage regressed 1

5. Target long-term BP: 120-129 mmHg systolic for most adults 1

Common Clinical Pitfalls

• Don't treat the BP number alone in asymptomatic patients—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated. 1

• Don't normalize BP acutely in chronic hypertensives—patients with chronic hypertension have altered cerebral autoregulation and cannot tolerate acute normalization. 1, 2

• Don't confuse subconjunctival hemorrhage with malignant hypertensive retinopathy—true malignant hypertension requires bilateral retinal hemorrhages, cotton wool spots, or papilledema. 1

• Don't use IV medications for hypertensive urgency—oral therapy with outpatient follow-up is appropriate. 1, 2

• Don't delay laboratory testing—immediate assessment is crucial for appropriate management. 1