This section covers Severe Asymptomatic hypertension, hypertensive urgency and hypertensive emergency treatment. For general treatment of hypertension please read Hypertension Treatment Guidelines.
Severe Asymptomatic Hypertension
ICD 10 Code = I10
These patients have severe hypertension (DBP ≥110 mmHg and/or SBP ≥180 mmHg), are asymptomatic and have no evidence of progressive target organ damage.
Keep the patient in the care setting and repeat BP measurement after resting for 1 hour.
If the second measurement is still elevated at the same level, start oral therapy using two medicines together, one of which should be low dose hydrochlorothiazide.
The second medicine is either a long-acting calcium channel blocker, e.g. amlodipine, or an ACE-inhibitor, e.g. enalapril.
Follow up carefully and refer as needed.
Hypertensive Urgency
ICD code = I10.
Description
Severe hypertension (DBP ≥110 mmHg and/or SBP ≥180 mmHg) which is symptomatic and/or with evidence of progressive target organ damage.
There are no immediate life threatening neurological or cardiac complications such as are seen in the hypertensive emergencies (see section).
Do not lower BP in acute stroke or use antihypertensive medication unless SBP >220 mmHg or the DBP >120 mmHg, as a rapid fall in BP may aggravate cerebral ischaemia and worsen the stroke.
Treatment may be given orally but in patients unable to swallow, use parenteral medicines.
Medicine Treatment
Ideally, all patients with hypertensive urgency should be treated in hospital.
Commence treatment with two oral agents and aim to lower the DBP to 100 mmHg slowly over 48–72 hours.
This BP lowering can be achieved by:
- Long-acting calcium channel blocker.
- ACE-inhibitor. Note: Avoid if there is severe hyponatraemia, i.e. serum Na <130 mmol/L.
- Spironolactone
- ß-blocker
Diuretics may potentiate the effects of the other classes of medicines when added. Furosemide should be used if there is renal insufficiency or signs of pulmonary congestion.
Hypertensive Emergency
ICD code = I10.
Description
This is a life-threatening situation that requires immediate lowering of BP usually with parenteral therapy.
Grade 3-4 hypertensive retinopathy is usually present, together with impaired renal function and proteinuria.
The true emergency situation should preferably be treated by a specialist.
Life-threatening complications include:
- Hypertensive encephalopathy, i.e. severe headache, visual disturbances, confusion, seizures and coma that may result in cerebral haemorrhage.
- Unstable angina or myocardial infarction.
- Acute left ventricular failure with severe pulmonary oedema (extreme breathlessness at rest).
- Eclampsia and severe pre-eclampsia.
- Acute kidney failure with encephalopathy.
- Acute aortic dissection
Medicine Treatment of Hypertensive Emergency
Admit the patient to a high-care setting for intravenous therapy and close monitoring. Do not lower the BP by >25% within 30 minutes to 2 hours.
In the next 2–6 hours, aim to decrease the BP to 160/100 mmHg. This may be achieved by the use of intravenous or oral medicines.
Intravenous therapy guidelines
Labetalol, IV, 2 mg/minute to a total dose of 1–2 mg/kg, while trying to achieve control with other agents.
- Caution in acute pulmonary oedema.
OR
If myocardial ischaemia and CCF:
Glyceryl trinitrate, IV, 5–10 mcg/minute.
AND
Furosemide, IV, 40–80 mg.
- Duration of action: 6 hours.
- Potentiates all of the above medicines
Oral therapy guidelines
ACE-inhibitor, e.g.:
Enalapril, oral, 2.5 mg as a test dose.
- Increase according to response, to a maximum of 20 mg daily.
- Monitor renal function.
If ACE-inhibitor intolerant, i.e. intractable cough:
Angiotensin receptor blocker (ARB), e.g. Losartan, oral, 50–100 mg daily. Specialist initiated.
To learn more about hypertensive emergencies, read this article.