Immediate management of severe hypertension.

A patient with a hypertensive crisis should be ideally treated in an intensive care unit. The choice of oral versus parenteral drug depends on the urgency of the situation, as well as the patient's general condition. The level to which the blood pressure should be lowered varies with the type of hypertensive crisis and should be individualized. The choice of parenteral drug is dictated by the clinical manifestations and concomitant medical problems associated with the hypertensive crisis. There is no predetermined level for the goal of therapy. Complications of therapy, mainly hypotension and ischemic brain damage, can occur in patients given multiple potent antihypertensive drugs in large doses without adequate monitoring. Such complications can be minimized by gentle lowering of blood pressure, careful surveillance, and individualization of therapy. A relatively asympatomatic patient who presents with severe hypertension, that is, a diastolic blood pressure 130 to 140 mm Hg, need not be treated with parenteral drugs. These patients should be managed on an individual basis, and the usual course would be to intensify or alter the previous antihypertensive therapy. Often, asymptomatic patients or those without an acute problem are unnecessarily subjected to immediate therapy. Acute alteration of the height of the mercury column does little good and may cause harm. A significant immediate change in the patient's blood pressure may be self-gratifying to the physician but is not indicated for most patients with asymptomatic severe hypertension. Indiscriminate use of therapeutic options such as nifedipine and furosemide should be discouraged strongly. Once the patient's condition is stable, one should evaluate the patient for possible factors that may have contributed to the dangerous elevation of blood pressure, such as nonadherence to prescribed therapy or the presence or progression of a secondary form of hypertension such as a renal artery stenosis. It is crucial to recognize not only what is a hypertensive crisis but also what is not an emergency.