Severely elevated blood pressure without symptoms

Patients with severely elevated blood pressure (BP) above 180/110 mmHg but without symptoms do not usually require immediate treatment and can be managed in the community. However, consider referral or admission to hospital for patients who are pregnant or have other factors that increase the risk of hypertensive complications—see Factors to consider in the management of severely elevated blood pressure. Also consider the patient’s BP history (if known), and the feasibility of observation or follow-up in the community.

Before starting BP-lowering therapy for patients with severely elevated BP but without symptoms, allow a period of observation with repeated measurement to see if BP settles without intervention. It is reasonable to reduce BP slowly over hours to days, and this may occur without intervention.

For a patient who takes regular BP-lowering drugs but has not had their usual dose, it is reasonable to give the regular drugs, provided there are no acute contraindications.

For patients who do not take regular BP-lowering drugs, or who have not missed any doses of their regular drugs, there is not usually an urgent need to start a new drug. Junior doctors managing a patient in hospital should consider consulting staff who are more experienced or familiar with the patient before prescribing a new drug.

Consider starting or adding new therapy with standard BP-lowering drugs if BP does not settle without intervention or following administration of a missed dose. See Approach to drug therapy for blood pressure reduction for information on BP-lowering drugs.

Follow-up within a few days is usually recommended to ensure BP is adequately controlled.

If a patient is referred to hospital by their general practitioner because of a persistent severely elevated BP that has not responded to the above measures, or the presence of risk factors for hypertensive complications (see Factors to consider in the management of severely elevated blood pressure), consider investigations (eg electrocardiography, chest X-ray, urinalysis, liver biochemistry, kidney function tests) to detect end-organ damage or dysfunction. Admission to hospital may be appropriate, particularly if follow-up is unlikely to occur.