Hypertension

High BP seldom warrants acute intervention. Your only concern should be whether this represents a hypertensive emergency or whether the hypertension reflects a more serious underlying process.  Anything else should be managed by the primary physician(s) during the daytime.

1.     Do you believe the reading? Take BP yourself if in doubt; use the right size cuff.

2.     Do a chart biopsy and note the time course of hypertension. Has it been constant since admission, or has it developed suddenly?

3.     Rule out underlying conditions causing hypertension based on a chart biopsy and focused H&P. Treat the underlying condition rather than the BP.

  • Alcohol withdrawal (tachycardia, tremor, confusion)
  • Drug overdose (cocaine, amphetamine)
  • Drug interactions (MAO inhibitors, tricyclics)
  • Drug withdrawals (blockers, ACE inhibitors, central alpha blockers)
  • Increased intracranial pressure (Cushing?s reflex)
  • ESRD, renal failure, renal artery stenosis
  • Eclampsia, pre-eclampsia (is the patient pregnant?)
  • Coarctation of the aorta, aortic dissection (unequal BP in arms?)
  • Pheochromocytoma (episodic nature; associated with flushing, diaphoresis, tachycardia)
  • Endocrine (Cushing's syndrome, thyrotoxicosis)

4.     Hypertensive emergency exists when elevated BP is associated with end-organ damage (brain, eye, heart, and kidney) whereas hypertensive urgency implies an elevated BP of > 200/120 but no evidence of end-organ damage. Ask about and examine:

  • Brain: headache, confusion, lethargy, stroke
  • Eye: blurred vision, papilledema, flame hemorrhages
  • Heart: chest pain, SOB, S3, S4, ECG strain or ischemic changes
  • Kidney: low urine output, edema, hematuria

5.     Hypertensive emergencies require admission to the ICU and reduction of BP by 25% over 6-12 hours with IV medications.  Your choices include:

  • Nitroprusside 0.3 mcg/kg/min and titrate up (requires arterial line BP monitoring and ICU stay).
  • Labetolol 20 mg IV q10 min until BP down; alternatively, infusion dosed at 0.5 ? 3.0 mg/min.
  • Nitroglycerin 5 mcg/min and titrate up (use when heart disease present; requires ICU stay).

6.     For hypertensive urgencies, remember that in a patient who has "lived at this level" of hypertension for a while, a large acute reduction in BP may change an asymptomatic patient into a symptomatic one (precipitate cerebral/myocardial ischemia).  If you decide to intervene, suggestions include:

  • Nitropaste is easy and can be easily removed (but can cause HA); see Sliding Scales: Nitropaste; captopril 6.25-25 mg po TID (check K, Cr, allergies before); Clonidine 0.1 mg po bid.
  • Avoid short-acting nifedipine (increased mortality).

7.     Special situation: In patients with an acute CNS process (i.e. during/post-CVA), HTN is usually compensatory and should be permitted as long as the BP is < 220/110.

Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356:411-7.