Chapter 44: Hypertensive Emergencies and Urgencies
A 56-year-old man presents to the Emergency Department complaining of a gradually worsening headache, unresponsive to acetaminophen, over the last 2 hours. He has had hypertension for 6 years, but “ran out” of his usual medications (hydrochlorothiazide and lisinopril) 2 weeks ago. Vital signs are unremarkable except for a blood pressure of 226/128 mm Hg (right arm seated) with a regular pulse rate of 80 beats/min. Funduscopic and general physical examinations are unremarkable. Laboratory studies, including a urinalysis, are within the reference ranges. A computed tomographic scan of his head discloses no abnormalities. The most appropriate next step in the management of this patient is which of the following?
A. Crushed captopril 25 mg dissolved in 60 mL of water, orally, now.
B. Nifedipine 10 mg capsule, “bite and swallow” now.
C. Oral clonidine, 0.2 mg now, and 0.1 mg each hour until the blood pressure is less than 160/100 mm Hg.
D. Refill his chronic medications, and refer to an appropriate source of primary care.
E. Sodium nitroprusside intravenously, starting at 0.3 μg/kg/min.
The answer is D. The patient described has no ongoing acute target organ damage, so this cannot be a hypertensive emergency. Some physicians would diagnose this man with a hypertensive urgency, but several recent papers suggest that intensive or even acute drug treatment in such a situation has not improved outcomes (Patel et al, 2016; Levy et al, 2015). Others would argue that “a hypertensive urgency” is not an evidence-based diagnosis, and should be stricken from the ICD-10 codes (Heath I: Hypertensive urgency—is this a useful diagnosis [editorial]. JAMA Intern Med. 2016;176:988–989). The most important thing for this patient is to replenish the medications he has exhausted, and connect him with an ongoing source of primary care. Crushed tablets of, or sublingual, captopril have both been studied in this setting, despite variable oral absorption rates, variable acute effects on blood pressure (with some hypotension reported); this treatment modality is more commonly used in Brazil than in the United States (Souza LM, et al. Oral drugs for hypertensive urgencies: systematic review and meta-analysis. Sao Paulo Med J. 2009;127;366–372). Nifedipine capsules have also been studied after being given sublingually or orally; sublingual absorption is minimal, whereas puncturing the capsules and delivering the medication orally can cause rapid hypotension, stroke, myocardial infarction, and death. The FDA declined to approve nifedipine capsules for acute treatment of hypertension because of this (Winker MA. The FDA’s decisions regarding new indications for approved drugs: where’s the evidence? JAMA. 1996:276:1342–1343). “Clonidine loading” was a popular treatment option in the 1980s and 1990s, and was studied prospectively by Kathleen Zeller and colleagues (Zeller KR, von Kuhnert L, ...