Urgent Neurological Evaluation for Unilateral Arm Symptoms with Hypertension

Immediate Assessment and Diagnostic Approach

The American Heart Association recommends measuring blood pressure in both arms immediately to detect discrepancies suggesting aortic pathology or renovascular disease 1
A focused neurological examination should be performed, looking specifically for arm weakness, drift, or coordination deficits, facial asymmetry, speech abnormalities, and sensory changes 1, 2
The American College of Cardiology recommends obtaining an ECG immediately to evaluate for atrial fibrillation or acute coronary syndrome 1
If BP ≥180/110 mmHg with acute neurological symptoms, this constitutes a hypertensive emergency requiring immediate hospitalization, according to the American Heart Association 1

The European Society of Cardiology recommends not relying solely on CT scan - proceed to MRI if CT is negative but clinical suspicion remains high, as MRI is more sensitive for acute ischemia 1
Fundoscopy for hypertensive retinopathy should be performed to assess for acute end-organ damage 1
Primary aldosteronism is a relevant secondary cause, presenting with hypertension and muscle cramps or weakness from hypokalemia, affecting 8-20% of hypertensive patients, according to the American Heart Association 2, 4

The European Society of Cardiology recommends initiating combination antihypertensive therapy immediately, rather than monotherapy, with a preferred combination of RAS blocker plus dihydropyridine calcium channel blocker 3, 5
The target BP should be systolic 120-129 mmHg, diastolic <80 mmHg if well tolerated, according to the European Society of Cardiology 3, 5

The American Geriatrics Society recommends assessing orthostatic BP changes if the patient is stable, and avoiding excessive diastolic BP lowering (keep DBP >60 mmHg) as it increases fall risk and may worsen coronary perfusion 1, 3
The American College of Cardiology recommends screening for moderate-to-severe frailty using validated clinical tests, and considering less aggressive BP target (140/90 mmHg) if frail 3
The European Society of Cardiology recommends using the ALARA principle ("as low as reasonably achievable") if the patient cannot tolerate target of 120-129 mmHg 3, 5