What is the appropriate management for an asymptomatic 86‑year‑old woman with severe hypertension (220/104 mmHg)?

Management of Asymptomatic Severe Hypertension in an 86-Year-Old Woman

This patient requires prompt initiation of oral antihypertensive therapy with close outpatient follow-up, not emergency hospitalization, because she lacks evidence of acute target-organ damage.

Immediate Assessment: Distinguish Emergency from Urgency

• Confirm the blood pressure reading by repeating the measurement at least twice more using a validated device with appropriate cuff size after the patient has rested for 5 minutes 1

• Rapidly assess for acute target-organ damage within minutes to distinguish hypertensive emergency from urgency 2:

  • Neurologic: altered mental status, severe headache with vomiting, visual disturbances, seizures, or focal deficits suggesting hypertensive encephalopathy or stroke 2
  • Cardiac: chest pain or dyspnea with pulmonary edema indicating acute coronary syndrome or left-ventricular failure 2
  • Ophthalmologic: perform fundoscopy looking for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) defining malignant hypertension 2
  • Renal: acute oliguria or rising creatinine suggesting acute kidney injury 2

• The presence or absence of acute target-organ damage—not the absolute blood pressure value—is the sole criterion distinguishing emergency from urgency 2

Classification: Hypertensive Urgency

• This patient has hypertensive urgency (BP 220/104 mmHg without acute target-organ damage), which should be managed with oral medications and outpatient follow-up; hospitalization and IV therapy are not indicated 2, 1
• Avoid rapid blood pressure lowering in asymptomatic patients, as it may cause cerebral, renal, or coronary ischemia, especially in elderly patients with chronic hypertension and altered cerebral autoregulation 2, 1

Initial Pharmacologic Management

First-Line Oral Therapy

For this 86-year-old patient, initiate combination therapy given the severity of elevation:

• Start with an ARB plus a dihydropyridine calcium channel blocker as preferred initial therapy 3:

  • Losartan 50 mg once daily 4 PLUS
  • Amlodipine 5 mg once daily 3

• The 2024 ESC guidelines recommend combination therapy as initial treatment for most patients with confirmed hypertension (BP ≥140/90 mmHg), with an exception to consider for patients aged ≥85 years 3

• However, given this patient's markedly elevated BP (220/104 mmHg), combination therapy is appropriate even at age 86 3

Alternative Approach for Very Elderly or Frail Patients

• If the patient has moderate-to-severe frailty or symptomatic orthostatic hypotension, consider starting with monotherapy at a lower dose and titrating more gradually 3
• In this case, start with losartan 25 mg once daily or amlodipine 2.5-5 mg once daily 3, 4

Blood Pressure Targets and Timeline

• Initial goal: Reduce BP by at least 20/10 mmHg over the first few weeks, aiming for <160/100 mmHg within 24-48 hours 2, 1
• Long-term target: The 2024 ESC guidelines recommend treating systolic BP to 120-129 mmHg in most adults, provided treatment is well tolerated 3
• For patients ≥85 years: The guidelines recommend maintaining BP-lowering treatment lifelong if well tolerated, but acknowledge that achieving 120-129 mmHg may not be feasible in all elderly patients 3
• Achieve target BP within 3 months through gradual titration 1

Titration Strategy

If BP remains >130/80 mmHg after 2-4 weeks:

• Increase losartan to 100 mg once daily (maximum dose) 4
• Increase amlodipine to 10 mg once daily (maximum dose) 3

If BP remains uncontrolled on two-drug combination:

• Add a thiazide-like diuretic: chlorthalidone 12.5 mg once daily, which can be increased to 25 mg daily if needed 3, 5
• Preferably use a single-pill combination to improve adherence 3

If BP remains uncontrolled on three-drug combination:

• Consider adding spironolactone 25 mg once daily if potassium <4.5 mmol/L and eGFR adequate 3

Monitoring and Follow-Up

• Schedule outpatient follow-up within 2-4 weeks to assess response to therapy, medication adherence, and orthostatic hypotension 2, 1
• Monitor electrolytes and renal function 2-4 weeks after initiating or adjusting diuretic therapy 1
• Monthly follow-up visits until target BP <130/80 mmHg is consistently achieved 2, 1
• Initiate home BP monitoring to track progress and improve adherence, with a target home BP <130/80 mmHg 1

Lifestyle Modifications

• Adopt a Mediterranean or DASH diet to help reduce BP and cardiovascular risk 3
• Restrict sodium intake and increase dietary potassium 3, 6
• Limit alcohol consumption to less than 100 g/week of pure alcohol, or preferably avoid alcohol entirely 3
• Restrict free sugar consumption to a maximum of 10% of energy intake 3
• Encourage regular physical activity appropriate for age and functional status 3, 6

Critical Pitfalls to Avoid

• Do not admit to hospital or use IV medications for asymptomatic severe hypertension without evidence of acute target-organ damage 2, 1
• Do not use immediate-release nifedipine, which can cause unpredictable precipitous BP drops, stroke, and death 2
• Do not rapidly lower BP in the absence of organ damage, as this raises the risk of ischemic complications, particularly in elderly patients with altered cerebral autoregulation 2, 1
• Do not assume absence of symptoms equals absence of organ damage—a focused exam including fundoscopy is essential 2
• Do not dismiss the need for treatment based on age alone; the 2024 ESC guidelines recommend maintaining BP-lowering treatment lifelong, even beyond age 85, if well tolerated 3
• Monitor for orthostatic hypotension at each visit, as elderly patients are at higher risk 3, 7

Special Considerations for Very Elderly Patients

• Start with lower doses and bring the pressure down more slowly in elderly patients, monitoring for orthostatic hypotension, impaired cognition, and electrolyte abnormalities 7
• If BP-lowering treatment is poorly tolerated and achieving 120-129 mmHg is not possible, target a systolic BP level that is "as low as reasonably achievable" (ALARA principle) 3
• Screen for secondary hypertension after stabilization, as 20-40% of malignant hypertension cases have identifiable causes (renal artery stenosis, primary aldosteronism, renal parenchymal disease) 2

Prognosis

• Untreated hypertensive emergencies carry a >79% one-year mortality and median survival of only 10.4 months, but this patient has urgency, not emergency 2
• Medication non-adherence is the most common precipitant of hypertensive crises; emphasize adherence to prevent progression 2