Management of Severe Hypertension

Nearly 50% of adults in the United States are affected by hypertension. Over 10% of these adults have severe hypertension, which is defined as blood pressure (BP) of 180/110 mm Hg or greater. Hypertension is estimated to impact 33% of the world’s population with Peru and Canada having the lowest prevalence (approximately 20%). The worldwide prevalence of hypertension has roughly doubled since 1990. Regions with the highest prevalence (greater than 50%) include Latin America, Oceania, Central Asia, and Eastern/Central Europe. American Family Physician recently published a review of Severe Hypertension: Evaluation and Treatment.

Severe hypertension in the outpatient setting is often due to medication nonadherence; whereas, anxiety, pain, hypervolemia, and not receiving home medications are the most common causes in the hospital. Signs concerning for secondary hypertension include onset in persons younger than 30 years, progressive BP elevation, resistant hypertension (BP uncontrolled despite maximum doses of 3 antihypertensive medications, including a diuretic), and premature end organ damage (eg, renal insufficiency). Causes of secondary hypertension from most to least common include obstructive sleep apnea, renovascular hypertension, alcohol or drug use, kidney parenchymal disease, primary aldosteronism, hyperthyroidism, coarctation of aorta, and Cushing syndrome.

In the absence of end organ damage, severe hypertension is not associated with adverse effects in the short term. However, aggressive treatment of severe hypertension in the hospital setting is associated with an increased risk of stroke, myocardial infarction, acute kidney injury, readmission, prolonged stay, and death. Over 40% of hospitalized patients with severe hypertension were found to have reduced BP (less than 140/90 mm Hg) within 3 hours of evaluation without treatment, showing that aggressive treatment is often unnecessary and may be harmful. Diagnostic testing for severe hypertension (eg, troponin level) is not recommended in the absence of new or acutely progressive end organ damage or suspected secondary hypertension.

Treatment of severe hypertension varies by setting. In the hospital, inciting factors such as anxiety, sleep deprivation, urinary retention, and substance use should be treated before initiation of antihypertensive medications. Additionally, discontinuation of medications that may contribute to hypertension (eg, corticosteroids) should be considered. Home antihypertensive medications that have been held on admission should be restarted. The BP may then be re-evaluated a few hours later. If BP is less than 180/110 mm Hg, no additional treatment is necessary and follow-up with home BP monitoring is recommended. If severe hypertension persists, oral medications may be considered for patients at high risk for cardiovascular complications or previous severe outpatient hypertension.

Outpatient treatment of severe hypertension without symptoms of end organ damage can be managed over days to weeks. In patients with chronic hypertension, treatment of underlying factors (eg, anxiety, sleep deprivation), is recommended initially. If BP remains elevated or no underlying factors are present, medication adherence should be assessed and antihypertensive medication should be titrated to goal BP per guidelines. For patients without a history of chronic hypertension in whom severe hypertension persists despite addressing underlying factors, home BP monitoring is recommended to distinguish primary hypertension from white coat hypertension.