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Severe Hypertension
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Severe Hypertension

Topics / Medical / Hypertension

Hypertension can be defined as blood pressures that are persistently elevated above 140/90mmHg. The classification of blood pressures is as follows:

Severe hypertension occurs when the blood pressure is in the grade 3 stage.

1. Asymptomatic Severe Hypertension

It refers to severe hypertension (stage 3 hypertension with an SBP ≥ 180mmHg and/or a DBP ≥ 110mmHg) in which the patient is asymptomatic. The patient may or may not have evidence of target organ damage

Management

  1. Administer 5mg Diazepam sublingually and measure the BP after resting for 1 hour
  2. If the blood pressure is still elevated, start oral antihypertensive using 2 drugs. One must be a low-dose thiazide-like diuretic and the second agent must either be Long-acting CCB (Amlodipine) or ACEI (Enalapril)
  3. Follow up with the patient within 1 week

2. Hypertensive Urgency

Patient may be asymptomatic, however patient usually present with symptoms such as severe headaches, shortness of breath and oedema and/or evidence of target organ damage. Not immediately life threatening (neurological, renal, eye or cardiac complications). 

Management

  1. Administer 5mg Diazepam sublingually and measure the BP after resting for 1 hour
  2. If still elevated 1 hour later, start with 2 oral agents with the aim of lower the DBP to 100mmHg slowly over 48-72hr.
    • A diuretic (preferably thiazide-like unless contraindicated) is used with one of the following:
      1. Long acting CCB eg Nifedipine SR 30mg daily , Amlodipine 10mg daily
      2. ACEI eg Enalapril 5mg BD (avoid if hyponatremia)
      3. B-Blocker: eg Carvedilol 12.5mg BD increasing to 25mg BD (Atenolol is no longer advised for the management of hypertension). B-Blockers are also considered as second line.

If the patient has a stroke and the Blood pressure is SBP <220mmHg/DBP <120mmHg: Treat the pain, agitation, nausea, and hypoxemia. Do not reduce the mean arterial pressure too rapidly because this will worsen the cerebral perfusion pressure and worsen the area of ischemia. Only treat the Blood pressure urgently if a hypertensive emergency co-exists.

If the patient has a stroke and the Blood pressure is SBP >220mmHg/DBP >120mmHg: We should aim to reduce the BP by 10-15% to a BP < 185/110. We can use Labetalol 10-20mg IVI over 1-2min followed by a 2-4mg/min infusion. We should initiate the patient on two oral agents at the same time but avoid sublingual Nifedipine or ACE inhibitors.

3. Hypertensive Emergency

Severe hypertension presents as a life-threatening emergency that will require lowering the blood pressure immediately using IV or Oral medications. Should be treated in ICU.

Includes:

  1. Hypertensive encephalopathy
  2. Unstable angina/myocardial infarction
  3. Acute left ventricular failure with severe pulmonary oedema
  4. Eclampsia and severe pre-eclampsia
  5. Acute aortic dissection
  6. Acute Kidney Injury with encephalopathy

Management

  1. Admit patient to high care/ICU (IV therapy and monitoring)
  2. Avoid sublingual Nifedipine or ACEI
  3. If ICU not available attempt to lower the Blood Pressure over 24 hours to 160/100mmHg (which can be done with oral agents). Do not lower the blood pressure by >25% within 30mins-2hours. Then in the next 2-6 hours aim to lower the blood pressure to 160/100mmHg.
  4. If an IV agent is used, a oral agent should also be initiated together with the IV agent. This allows earlier tapering and discontinuation with oral agents (allows of easier discontinuation of the IV agent later)
  5. The long term management may require 3-4 classes of drugs to adequately control the blood pressure below 140/90
  6. If Intravenous (can use):
    1. Labetalol: 10-20mg bolus and repeat after 10min, then infuse at 2mg/min. As mentioned above, initiate oral treatment simultaneously.
    2. Furosemide: 10-20mg IVI (use if the patient has oedema indicating fluid overload)
    3. Others: Nitroglycerin 5-15ug/min used if associated myocardial ischemia
  7. If Oral treatment (can use):

Oral agents can be used alone if the IV agents are not available. However, they should be added to the IV regime the same way it was used under the hypertensive urgency.

Abbreviations:
SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; TOD: Target Organ Damage; CCB: Calcium Channel Blocker; ACEI: ACE-Inhibitors

Published on 14 June 2022
Dr. RW Becerra Estevez
Dr. RW Becerra EstevezMBChB (WSU)

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