Hypertension
ABCs
- check vitals in both arms
- confirm accurate BP (proper cuff, repeat readings)
- cardiac monitor if symptomatic
- assess symptoms: headache, chest pain, neuro deficit
- look for end-organ damage
- BP ≥ 180/120 with symptoms
- neuro deficit → stroke
- chest pain → ACS / dissection
- dyspnea → pulmonary edema
- AKI → renal involvement
red flags
don’t miss
- BP ≥ 180/120 with symptoms
- new neurological deficit
- tearing chest or back pain (dissection)
- dyspnea + crackles (pulmonary edema)
- decreasing urine output, rising creatinine
HPI & examination
- assess for end-organ damage
- neuro → headache, confusion, blurry vision, focal deficits
- cardiac → chest pain, dyspnea
- renal → decreased urine output, hematuria
- GI → vomiting
- contributing factors
- pain, anxiety, agitation
- volume status (overload vs depletion)
- recent medication changes
- urinary retention
- review medication history (missed or held antihypertensives)
- focused exam
- neurological (if altered LOC or deficits)
- cardiopulmonary (volume status, pulses)
definitions
- normal: <120/80
- elevated: 120-129 / <80
- hypertension: ≥130/80
- severe: ≥180 systolic or ≥120 diastolic
management
severe hypertension (no end-organ damage)
- no immediate BP lowering required
- treat contributing factors (pain, anxiety, etc.)
- resume or adjust oral medications
- arrange follow-up
BP ≥ 180/100 or symptomatic / end-organ damage
- chest pain → Hs-trop & ECG
- dyspnea / overload → CXR ± BNP
- headache / neurological deficits → arrange CT brain
- renal concern → RFT & UA
target BP
- reduce MAP by 10-20% in 1st hour, further 5-15% over 24 hours UNLESS:
- ischemic stroke → do not lower BP unless ≥ 220/120 (180/105 if post-tPA)
- aortic dissection → rapid reduction to 100-120 mmHg within ~20 min
- intracranial hemorrhage → follow specific guidance
labetalol IV
- bolus 20 mg IV, repeat 20-80 mg q10min (max 300 mg)
- infusion 0.5-2 mg/min after 20 mg bolus
- avoid if: asthma/COPD, HF, bradycardia, pheochromocytoma, cocaine/meth intoxication
avoid hydralazine — unpredictable drop
drug avoidance
| condition | avoid |
|---|---|
| angioedema | ACE inhibitors |
| bronchospastic disease | non-selective beta blockers |
| liver disease | methyldopa |
| pregnancy | ACEi, ARB, renin inhibitors |
| heart block | beta blockers, non-DHP CCBs |
| renovascular disease | ACEi, ARB, renin inhibitors |
| depression | beta blockers, central alpha-2 agonists |
| gout | loop or thiazide diuretics |
| hyperkalemia | ACEi, ARB, aldosterone antagonists |
| hyponatremia | thiazide diuretics |
studying for the IM exam? the IM Rapid Review covers blood pressure management in the same format. see the sample chapter.
Last reviewed · May 2026