Management of Persistent Severe Hypertension

Immediate Assessment and Treatment

The European Society of Cardiology recommends adding a second antihypertensive agent, specifically an ACE inhibitor or ARB, immediately to amlodipine for patients with severe hypertension without emergency features, rather than waiting or increasing the amlodipine dose alone 1
For patients with severe hypertension and signs of end-organ damage, such as hypertensive encephalopathy or acute coronary syndrome, IV therapy with labetalol as first-line is recommended, with a target of reducing mean arterial pressure by 20-25% over several hours 2, 3

The European Society of Cardiology recommends adding an ACE inhibitor, such as perindopril 2 mg daily, or an ARB, such as losartan 50 mg daily, to amlodipine for patients with severe hypertension without emergency features 1, 4, 5
The target blood pressure is <140/90 mmHg for general hypertension, and <130/80 mmHg for patients with heart failure or coronary artery disease 1, 6, 8
If blood pressure remains ≥160/100 mmHg after 2 weeks of combination therapy, adding a thiazide-like diuretic, such as indapamide 2.5 mg daily, is recommended 1, 4

For patients with heart failure with reduced ejection fraction, the recommended target blood pressure is <130/80 mmHg, and the foundation of treatment is ACE-I/ARB + beta-blocker + aldosterone antagonist + diuretic 6, 7
For patients with coronary artery disease, beta-blockers and ACE-I/ARB are preferred, with a target blood pressure of <130/80 mmHg 8
For patients with chronic kidney disease, ACE-I or ARB are essential components of treatment 1

Blood pressure should be rechecked in 2 weeks after adding the second agent, and home blood pressure monitoring is encouraged to assess treatment effectiveness 4, 5
The goal is to achieve target blood pressure within 3 months of initiating combination therapy, and referral to a hypertension specialist is recommended if blood pressure remains ≥160/100 mmHg on ≥3 drugs 1, 4, 5, 9