Hypertension

Evaluation

Physical examination

• Brain: headache, confusion, lethargy, stroke
• Eye: blurred vision
• Heart: Chest pain, dyspnea
• Kidney: low urine output, edema

Lab: not always required. Use selectively to determine cause and whether patient meets criteria for hypertensive emergency.

• CBC with peripheral smear
• EKG, troponin, BNP
• UA (looks for proteinuria), electrolytes, BUN and creatinine (look for renal dysfunction)
• CXR if chest pain or dyspnea
• Head CT for those with neurologic symptoms
• Chest CT with contrast in patients with severe chest pain, unequal BP in arms, unequal pulses, or widening of mediastinum on CXR

Management

For hypertensive urgencies: Majority of patient with HTN have no acute end organ damage and their BP can be lowered over days with oral medications. Consider rechecking BP after 30 minutes of quiet rest. Restarting a patient's home med is a good first step. Alternatively, consider starting one or more long acting oral med that can be continued on discharged.

• Amlodipine 5-10mg PO daily
• Lisinopril 10-20mg PO daily or losartan 25-50mg daily

In cases where more rapid lowering and closer tritration of BP is desired, consider shorter acting med

• Captopril 6.25-25mg PO TID
• Clonidine 0.1mg BID. can titrate to TID. DUe to the risk of rebound HTN, often reserved for resistant HTN
• Hydralazine 10mg PO q8hr can increase to q6hr. use with caution due to unpredictable effect and reflex tachycardia

For Hypertensive emergencies

• Labetalol: 10-20mg IV initial, followed by 10-80mg IV q10 mins until BP falls
• Nicardipine: Initial infusion of 5mg/hr, increasing by 2.5mg/hr every 5 mins to a maximum dose of 15mg/hr. Watch out for reflex tachycardia
• Nitroprusside: 0.3mcg/kg/min-4mcg/kg/min
• Esmolol: 0.5mg/kg loading dose, followed by starting infusion of 50mcg/kg/min up to 200mcg/kg/min