Day 4 - Hypertension

Hypertensive Emergency

Defined as: Severe hypertension (>180/120) with evidence of end organ damage

• Neurologic changes

  • Stroke

  • Seizure

  • Elevated ICP

• Cardiac injury

• Pulmonary edema

• Aortic Dissection

Initial Treatment:

Target - gradual reduction of 10-20% in first hour and additional 5-15% over the next 23 hours

• Labetalol 20mg IV bolus x 1, then labetalol infusion 0.5 - 2mg/min

• Nitroglycerin 5-100mcg/min

Hypertensive emergencies generally are admitted to critical care/cardiology units as they require continuous blood pressure monitoring for titration of anti-hypertensive infusions.

Acute In-Hospital Management of Hypertension

Address Etiologies of Worsening Hypertension

• Pain

• Anxiety

• Agitation

• Urinary retention, Constipation

• Withdrawal

• Missed home hypertension medication

Initial Pharmaceutical Management of Asymptomatic Hypertension

• Restart Home medication

• New hypertension?

  • Investigate for aetiologies of worsening hypertension in hospital

  • If hypertension is persistent and patient likely has essential hypertension - start with LOW dose anti-hypertensive medication

    • Amlodipine 2.5-5mg PO daily

    • Ramipril 2.5 - 5mg PO daily

    • Perindopril 2-4mg PO daily

    • Chlorthalidone 2.5 mg PO daily

    • Hydrochlorothiazide 12.5mg PO daily

• Worsening hypertension?

  • If not severe, avoid intensifying anti-hypertensive medication

  • If severe, increase home medication first

  • Increasing evidence that intensifying anti-hypertensive regimens in hospital have increased risks of adverse events and re-admission, with no mortality benefit at one year.

• IV medications such as hydralazine should be avoided in asymptomatic hypertension.