How should I manage a 52‑year‑old man with hypertension who presents with three days of persistent hiccups, dizziness, headache, right‑sided conjunctival hemorrhage and severely elevated blood pressure?

Management of a 52-Year-Old Man with Hypertensive Emergency

Immediate Classification: This is a Hypertensive Emergency

This patient requires immediate ICU admission with continuous arterial-line monitoring and intravenous antihypertensive therapy. 1 The combination of severely elevated blood pressure (182/87,173/102 mmHg) with three days of persistent hiccups, dizziness, headache, and conjunctival hemorrhage indicates potential acute target-organ damage requiring urgent evaluation and treatment.

Rapid Bedside Assessment for Target-Organ Damage (Complete Within Minutes)

Before initiating IV therapy, you must actively exclude or confirm acute organ injury: 1

Neurologic Assessment

• Perform a focused mental status exam looking for altered consciousness, confusion, or lethargy that may indicate hypertensive encephalopathy 1
• The persistent hiccups combined with dizziness and headache raise concern for posterior circulation involvement or brainstem dysfunction 1
• Assess for visual disturbances, seizure activity, or focal neurologic deficits 1
• Consider urgent non-contrast head CT if any neurologic findings are present 1

Ophthalmologic Examination

• Perform dilated fundoscopy immediately to look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) that would confirm malignant hypertension 1
• Note: The unilateral conjunctival hemorrhage alone is NOT acute target-organ damage, but bilateral retinal findings would be 1

Cardiac Assessment

• Evaluate for chest pain, dyspnea, or pulmonary edema suggesting acute coronary syndrome or left ventricular failure 1
• Obtain ECG and troponin to assess for myocardial injury 1

Renal Evaluation

• Check serum creatinine, electrolytes, and urinalysis for proteinuria or abnormal sediment 1
• Obtain CBC, LDH, and haptoglobin to screen for thrombotic microangiopathy 1

Initial Blood Pressure Management Strategy

If Target-Organ Damage is Confirmed (Hypertensive Emergency):

Admit to ICU immediately with continuous arterial-line monitoring (Class I recommendation). 1

Blood Pressure Targets:

• First hour: Reduce mean arterial pressure by 20-25% (or systolic BP by ≤25%) 1
• Hours 2-6: Lower to ≤160/100 mmHg if patient remains stable 1
• Hours 24-48: Gradually normalize blood pressure 1
• Critical safety point: Avoid systolic drops >70 mmHg, as this can precipitate cerebral, renal, or coronary ischemia, especially in chronic hypertensives with altered autoregulation 1

First-Line IV Medication: Nicardipine

Nicardipine is the preferred agent for this patient because it preserves cerebral blood flow, does not increase intracranial pressure, and allows predictable titration. 1

Dosing protocol: 1, 2

• Start at 5 mg/hour IV infusion
• Increase by 2.5 mg/hour every 15 minutes until target BP is reached
• Maximum dose: 15 mg/hour
• Onset: 5-15 minutes; Duration: 30-40 minutes
• Administer via central line or large peripheral vein; change peripheral site every 12 hours 2

Alternative agent if nicardipine unavailable: Labetalol 10-20 mg IV bolus over 1-2 minutes, repeat or double every 10 minutes (max cumulative 300 mg), or continuous infusion 2-8 mg/min 1

If NO Target-Organ Damage is Found (Hypertensive Urgency):

Do NOT admit to hospital; manage with oral antihypertensives and outpatient follow-up. 1 However, given this patient's persistent symptoms over 3 days, thorough evaluation for subtle organ damage is essential before classifying as urgency.

Special Considerations for This Patient

The Persistent Hiccups are a Red Flag

• Persistent hiccups lasting 3 days combined with dizziness and headache may indicate:
  • Posterior circulation ischemia or brainstem involvement 1
  • Hypertensive encephalopathy with early brainstem dysfunction 1
  • This symptom complex warrants brain imaging (MRI with FLAIR is superior to CT for detecting posterior reversible encephalopathy syndrome) 1

The Conjunctival Hemorrhage

• While unilateral subconjunctival hemorrhage alone is NOT acute target-organ damage, it may indicate vascular fragility from chronic hypertension 1
• You must perform fundoscopy to look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema that would indicate malignant hypertension 1

Post-Stabilization Management

Screen for Secondary Causes

• 20-40% of patients with malignant hypertension have identifiable secondary causes including renal artery stenosis, pheochromocytoma, primary aldosteronism, or renal parenchymal disease 1
• Screening should be performed after acute stabilization 1

Address Medication Non-Adherence

• Medication non-adherence is the most common trigger for hypertensive emergencies 1
• Emphasize adherence to prevent recurrence 1

Long-Term Follow-Up

• Schedule monthly visits until target BP <130/80 mmHg is achieved and organ-damage findings regress 1
• Transition to oral regimen combining a RAS blocker, calcium-channel blocker, and diuretic after 24-48 hours of stabilization 1

Critical Pitfalls to Avoid

• Do NOT use immediate-release nifedipine – it causes unpredictable precipitous BP drops, stroke, and death 1
• Do NOT rapidly normalize BP in chronic hypertensives – altered cerebral autoregulation predisposes to ischemic injury 1
• Do NOT dismiss the symptom complex as simple urgency without thorough evaluation – the 3-day duration of hiccups, dizziness, and headache suggests evolving organ involvement 1
• Do NOT use oral agents for initial management if target-organ damage is confirmed – IV therapy is mandatory 1
• Do NOT delay brain imaging if neurologic symptoms persist or worsen 1

Prognosis

Without treatment, hypertensive emergencies carry a >79% one-year mortality and median survival of only 10.4 months. 1 Even with successful acute management, this patient will remain at markedly increased cardiovascular and renal risk requiring intensive long-term follow-up. 1