Patients requiring immediate blood pressure lowering

Franz H. Messerli

Does every patient with a blood pressure >180/100 mm Hg require urgent treatment and hospitalization? What antihypertensive agents should be used in general practice? How to quickly lower the blood pressure?

Franz H. Messerli: It is quite clear that such a patient needs to be treated. But let me be very specific. We do not treat numbers. We treat patients. You do not treat millimeters of mercury – you treat a patient effectively. And if such a patient, let’s say, is a heavyset African American who has not been on treatment for months, there is no urgency to bring his blood pressure down immediately. Of course, it needs to be brought down over time, but we do not have to make any big issue out of it. However, if such a patient has pulmonary edema and consists a hypertensive emergency, then you need to lower blood pressure right away.

As a general rule, if such a patient comes to your practice, why don’t you give 10 mg of amlodipine? There is very little harm you could do. We sometimes call amlodipine a no-brainer – you do not need to think too much, you could give it practically in any patient without any big contraindications. So administering 10 mg of amlodipine is a good idea, and then wait and see what happens. Usually over a few days blood pressure will come down. You add a blocker of the renal angiotensin system, and as a third line, I would add a diuretic. But there is no big rush in general to treat such a patient, except when it is a hypertensive emergency. And again, hypertensive emergencies are not defined by the blood pressure level. They are defined by the concomitant pathology that the patient has.

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