Initial assessment
In the presence of very high blood pressure values, usually with systolic blood pressure ≥ one hundred and eighty millimetres of mercury and/or diastolic blood pressure ≥ one hundred and twenty millimetres of mercury, the first step is to perform a structured clinical assessment. The initial objective is not immediate blood pressure reduction, but distinction between situations with and without acute target-organ damage, since this differentiation determines the therapeutic approach and the place of treatment.
Blood pressure confirmation
Blood pressure should be confirmed correctly, using an appropriately sized cuff, ensuring prior rest and repeating two to three measurements. Whenever aortic dissection is suspected, blood pressure should be measured in both upper limbs in order to identify relevant asymmetries.
Directed clinical history
The clinical history should be brief and targeted, assessing adherence to antihypertensive therapy, recent introduction of drugs potentially associated with blood pressure elevation, such as non-steroidal anti-inflammatory drugs, corticosteroids or sympathomimetics, use of illicit drugs, particularly cocaine or amphetamines, and the presence of chest pain, dyspnoea or neurological symptoms. In women, pregnancy or the postpartum period should always be assessed.
Physical examination
Physical examination should be focused, including a brief neurological assessment, search for signs of heart failure or acute pulmonary oedema, palpation of peripheral pulses to detect asymmetries, cardiac auscultation and, whenever available, fundoscopy to identify signs of acute hypertensive retinopathy.
Exclusion of acute target-organ damage
The presence of acute target-organ damage defines a hypertensive emergency. This includes conditions such as acute coronary syndrome or myocardial infarction, acute pulmonary oedema or acute heart failure, aortic dissection, ischaemic or haemorrhagic stroke, hypertensive encephalopathy, eclampsia or pre-eclampsia and rapidly progressive acute kidney injury, requiring immediate referral to the emergency department and directed complementary investigation.
Symptoms without acute target-organ damage
In the absence of acute damage, symptoms attributable to blood pressure elevation may be present and are non-specific, functional and reversible. These include severe or progressive headache, sensation of cranial pressure, dizziness, transient blurred vision without focal deficits, palpitations, non-specific chest tightness, mild dyspnoea without signs of pulmonary congestion, nausea, sweating, facial flushing, tremor and marked anxiety. These symptoms do not indicate acute structural damage.
Symptomatic hypertensive urgency
In the presence of very high blood pressure with non-specific symptoms, but without acute target-organ damage, blood pressure reduction should be gradual and cautious. The oral route should be preferred, avoiding abrupt reductions and not exceeding a decrease greater than twenty-five percent in the first hours, with the aim of achieving values below one hundred and sixty over one hundred millimetres of mercury over several hours to days. In older patients, reduction should be even slower because of the higher risk of cerebral and myocardial hypoperfusion.
Very high asymptomatic blood pressure
In very high asymptomatic blood pressure, without evidence of acute target-organ damage, there is no indication to reduce blood pressure at the time of assessment. The approach should focus on diagnostic confirmation, assessment of therapeutic adherence, review of reversible or precipitating causes, adjustment or intensification of chronic therapy and scheduling early follow-up, ideally within forty-eight to seventy-two hours or up to one week.
Reassessment and follow-up
After the initial assessment and any therapeutic adjustments, clinical and blood pressure reassessment is essential. Worsening symptoms or the appearance of signs suggestive of acute target-organ damage should prompt immediate reclassification of the situation and management as a hypertensive emergency. Gradual, individualised management focused on patient safety is essential to prevent iatrogenic complications.
