Pharmacotherapy Case Study 3: Hypertensive Crisis By: Dr. Nehad Ahmed

 

Chief Complaint:

The patient presents to the emergency department with a sudden onset of severe headache, blurred vision, and chest tightness. The patient reports feeling lightheaded and anxious for the past few hours.

Subjective Data:

History of Present Illness (HPI):
The patient presents with a headache that started suddenly about 4 hours ago, described as severe and throbbing, localized to the occipital area. The headache is associated with blurred vision and chest tightness. The patient also reports feeling lightheaded, dizzy, and more anxious than usual. There is no history of recent trauma, and the patient denies any abdominal pain, shortness of breath, or nausea. The patient has a history of poorly controlled hypertension but has not been following up regularly with their primary care provider.

Past Medical History (PMH):

Hypertension (diagnosed 5 years ago)

Hyperlipidemia

Obesity (BMI 30 kg/m²)

Chronic kidney disease (stage 1, mild)

No known history of cardiovascular disease (e.g., myocardial infarction, stroke)

Medications:

Lisinopril 10 mg daily

Atorvastatin 20 mg nightly

Metformin 500 mg twice daily

No recent use of over-the-counter medications, no history of illicit drug use.

Allergies:

No known drug allergies.

Family History:

Father with hypertension and type 2 diabetes mellitus

Mother with a history of stroke at age 65.

Social History:

Non-smoker

Occasional alcohol use (1-2 drinks per week)

Sedentary lifestyle, no regular exercise

Diet high in processed foods, low in fruits and vegetables

Review of Systems:

Cardiovascular: Chest tightness, no palpitations.

Neurological: Severe headache, blurred vision, no focal deficits.

Respiratory: No shortness of breath or wheezing.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Genitourinary: No changes in urinary frequency or appearance.

 

Objective Data:

Vital Signs upon Arrival:

Blood Pressure: 210/120 mmHg (right arm, seated position)

Heart Rate: 92 bpm

Respiratory Rate: 18 breaths/min

Temperature: 36.8°C

Oxygen Saturation: 98% on room air

Weight: 92 kg (BMI 30 kg/m²)

Height: 170 cm

Physical Exam:

General: Alert and anxious, visibly uncomfortable, no signs of acute distress.

Cardiovascular: Regular heart rate, no murmurs or gallops. No jugular venous distention.

Neurological: Alert and oriented, cranial nerves intact, no focal deficits. Mild papilledema noted upon fundoscopic examination.

Respiratory: Clear to auscultation bilaterally, no wheezing or crackles.

Extremities: No edema, pulses normal bilaterally.

Skin: Warm and dry, no rashes or lesions.

Laboratory Results:

Electrolytes: Sodium 141 mEq/L, Potassium 4.3 mEq/L

Creatinine: 1.2 mg/dL (slightly elevated from baseline)

Blood Glucose: 120 mg/dL (fasting)

Lipid Profile:

Total Cholesterol: 220 mg/dL

LDL: 140 mg/dL

HDL: 48 mg/dL

Triglycerides: 175 mg/dL

Urinalysis: Negative for protein, glucose, or blood.

ECG: Normal sinus rhythm, no signs of ischemia.

Imaging:

Chest X-ray: No acute findings, clear lung fields.

Head CT: No evidence of acute intracranial hemorrhage.

Assessment:

The patient presents with signs and symptoms consistent with a hypertensive crisis, likely a hypertensive emergency given the elevated blood pressure (210/120 mmHg) and the presence of target organ damage (headache, blurred vision, papilledema). The patient’s history of poorly controlled hypertension and mild chronic kidney disease (stage 1) further supports this diagnosis. The patient's symptoms of chest tightness and anxiety are concerning for potential cardiovascular events, though no acute ischemia is seen on the ECG.

 

 

Plan:

Immediate Management:

Admit to the hospital for close monitoring in a telemetry unit or intensive care unit (ICU), as the patient is at risk of end-organ damage.

Initiate IV antihypertensive therapy to reduce the blood pressure gradually over hours (target a 25% reduction in the first 1-2 hours).

Labetalol (IV): Start with 20 mg bolus, followed by 20-80 mg every 10 minutes as needed, up to a maximum dose of 300 mg.

Alternatively, Nicardipine (IV): Start at 5 mg/h, titrate up by 2.5 mg/h every 5-15 minutes until blood pressure is controlled (maximum 15 mg/h).

Monitor blood pressure every 5-15 minutes until it stabilizes, then every 30 minutes once blood pressure is near target.

Lab work to monitor renal function (creatinine, electrolytes) and assess for any worsening of kidney function.

 

Pharmacotherapy Adjustment:

Continue home medications (Lisinopril 10 mg daily and Atorvastatin 20 mg nightly).

Consider adding a long-acting antihypertensive medication after stabilization:

Amlodipine 5 mg daily for additional blood pressure control.

Hydrochlorothiazide (12.5 mg) daily if the blood pressure remains elevated after IV therapy.

 

Monitoring & Follow-up:

Frequent blood pressure monitoring during hospitalization, aiming to achieve a gradual reduction to <160/100 mmHg within the first 2-6 hours and then targeting <140/90 mmHg in the following 24-48 hours.

Renal function monitoring every 12 hours to check for worsening creatinine or electrolyte imbalances, given the patient's underlying chronic kidney disease.

Neurological monitoring for any signs of stroke or worsening symptoms, especially given the headache and papilledema.

Lifestyle Modifications:

Dietary changes to reduce sodium intake and encourage the DASH diet, which is rich in fruits, vegetables, and low-fat dairy products.

Exercise: Recommend at least 150 minutes of moderate-intensity aerobic exercise per week once the blood pressure is under control.

Weight loss to reduce the patient's BMI and improve overall cardiovascular health.

Alcohol reduction: Advise limiting alcohol intake to 1-2 drinks per day, with an emphasis on moderation.

Patient Education:

Hypertension management: Emphasize the importance of regular blood pressure monitoring, adherence to medications, and attending regular follow-up appointments.

Symptom recognition: Teach the patient to recognize the symptoms of hypertensive crisis, including headache, chest pain, blurred vision, and dizziness, and seek medical help immediately.

Adherence to therapy: Discuss the importance of consistent medication adherence, especially to antihypertensives and statins.

Follow-up:

Close outpatient follow-up within 1 week to reassess blood pressure control, consider adjusting medications, and ensure adherence to lifestyle changes.

Discussion:

Hypertensive crisis is a medical emergency characterized by a rapid and severe increase in blood pressure that can lead to significant end-organ damage. The patient’s symptoms of severe headache, blurred vision, and chest tightness are indicative of target organ damage, most notably in the eyes and potentially the heart. Immediate blood pressure reduction with intravenous antihypertensive therapy is essential to prevent further complications such as stroke, myocardial infarction, or acute kidney injury.

The main goal of treatment is to reduce the blood pressure gradually to avoid causing ischemic injury to the brain, heart, and kidneys. Long-term management of hypertension includes optimizing oral antihypertensive therapy, encouraging lifestyle modifications, and addressing any underlying risk factors like obesity and hyperlipidemia.

Prognosis:
With prompt and appropriate management, the patient's blood pressure can be controlled, and the risk of end-organ damage can be minimized. However, the patient will require close follow-up to ensure long-term control of hypertension and prevention of future hypertensive crises.