How should I titrate antihypertensive medications in a patient experiencing a hypertensive crisis in the community?

In a patient experiencing a hypertensive crisis in the community, antihypertensive medication titration should be approached with caution and urgency. Immediate same-day referral to specialist care is recommended if the patient has a clinic blood pressure of 180/120 mmHg or higher with signs of retinal hemorrhage, papilloedema (accelerated hypertension), or life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

If the patient does not have these severe symptoms but has a blood pressure of 180/120 mmHg or higher, investigations for target organ damage should be carried out as soon as possible. If target organ damage is identified, antihypertensive treatment should be started immediately without waiting for ambulatory or home blood pressure monitoring results.

When initiating or adjusting antihypertensive medications, ensure adherence to prescribed doses and review medications to confirm they are at optimal tolerated doses before titrating further. Titration should be gradual to avoid excessive blood pressure drops, especially monitoring for postural hypotension (a systolic drop of 20 mmHg or more or diastolic drop of 10 mmHg or more after standing for 1 minute), which requires medication review and appropriate management.

In resistant hypertension cases (uncontrolled blood pressure despite optimal tolerated doses of an ACE inhibitor or ARB, a calcium channel blocker, and a thiazide-like diuretic), consider adding a fourth drug such as low-dose spironolactone if potassium is ≤4.5 mmol/l, or an alpha-blocker or beta-blocker if potassium is >4.5 mmol/l, with careful monitoring of electrolytes and renal function.

Overall, titration in hypertensive crisis should be cautious, with close monitoring and specialist involvement as needed, prioritizing patient safety and preventing rapid blood pressure fluctuations.

Refer urgently for specialist assessment if severe symptoms or signs are present.

Summary:

• Urgent specialist referral if BP ≥180/120 mmHg with severe symptoms/signs.
• Start antihypertensives immediately if target organ damage is present.
• Review adherence and medication doses before titrating.
• Monitor for postural hypotension and adjust accordingly.
• Consider additional agents in resistant hypertension with specialist advice.

These steps align with NICE guideline NG136 on hypertension management in adults ¹.