What is the treatment for hypertensive urgency?

From the Guidelines

Hypertensive urgency should be treated with oral antihypertensive medications to gradually lower blood pressure over 24-48 hours, rather than rapid reduction. This approach is supported by the European Heart Journal's 2019 position document on the management of hypertensive emergencies 1. The goal is to reduce blood pressure by no more than 25% within the first few hours, then gradually to normal levels over the next 24-48 hours.

Key Considerations

• First-line options include labetalol 200-400 mg orally every 2-3 hours, captopril 25 mg orally, or amlodipine 5-10 mg once daily.
• Clonidine 0.1-0.2 mg orally, followed by 0.1 mg hourly until blood pressure is controlled (maximum 0.8 mg total) is another option.
• Patients should be monitored closely with frequent blood pressure checks during this period.
• Rapid blood pressure reduction should be avoided as it can lead to organ hypoperfusion, particularly in the brain, heart, and kidneys.
• The underlying cause of hypertension should be addressed simultaneously, which may include medication adherence issues, dietary factors, or secondary causes of hypertension.
• Patients should follow up within a week to ensure blood pressure control is maintained and to adjust long-term antihypertensive therapy as needed, as stated in the key messages of the esc council on hypertension position document 1.

Rationale

The rationale behind this approach is to avoid the risks associated with rapid blood pressure reduction, such as organ hypoperfusion, while still effectively managing hypertensive urgency. The European Heart Journal's position document emphasizes the importance of careful blood pressure reduction in patients with hypertensive emergencies, and the need to individualize treatment based on the specific clinical presentation and organ involvement 1.

Monitoring and Follow-up

Patients with hypertensive urgency should be closely monitored during the treatment period, with frequent blood pressure checks to ensure that the blood pressure is being lowered at a safe and effective rate. Follow-up appointments should be scheduled within a week to assess the patient's response to treatment and make any necessary adjustments to their antihypertensive therapy.

From the FDA Drug Label

Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. Sodium nitroprusside can be used for hypertensive urgency treatment, specifically for the immediate reduction of blood pressure in hypertensive crises.

• The treatment should be used with concomitant longer-acting antihypertensive medication to minimize the duration of treatment with sodium nitroprusside 2.

From the Research

Hypertensive Urgency Treatment

• Hypertensive urgency is defined as a severe elevation in blood pressure without end-organ injury, and the goal of treatment is to lower blood pressure gradually over 24 to 48 hours using oral antihypertensives 3.
• The choice of oral antihypertensive agent should be guided by the underlying pathophysiological and clinical findings, mechanism of action, and potential for adverse effects 3.
• Agents such as nifedipine, clonidine, captopril, and labetalol have been shown to be effective in lowering blood pressure in hypertensive urgencies 4, 5, 6.
• Nifedipine and captopril have a rapid onset of action, within 0.5-1 hour, while clonidine and labetalol have maximal blood pressure lowering effects at 2-4 hours 5.
• The selection of an oral antihypertensive agent should be based on the perceived need for urgent blood pressure control, the cause of the hypertensive urgency, and concomitant conditions 5.
• It is essential to note that there is no definitive benefit from acute blood pressure lowering in hypertensive urgencies, especially in asymptomatic patients, and more controlled trials are needed to assess the most appropriate treatment 5.

Oral Antihypertensive Agents

• Nifedipine: a dihydropyridine calcium-channel blocker with a rapid onset of action, but may increase heart rate 3, 5.
• Clonidine: an alpha-2 adrenergic agonist that decreases heart rate, but may cause sedation and mental impairment 3, 5.
• Captopril: an angiotensin-converting enzyme (ACE) inhibitor with a rapid onset of action, but should be avoided in patients with bilateral renal artery stenosis or unilateral renal artery stenosis in patients with a solitary kidney 3, 5.
• Labetalol: a beta-blocker with alpha-1 adrenergic blocking activity, but may cause bronchospasm and bradycardia or heart blocks 3, 5.

Treatment Approach

• In hypertensive urgencies, blood pressure should be lowered gradually over 24 to 48 hours using oral antihypertensives 3.
• The treatment approach should be individualized based on the patient's clinical presentation, medical history, and concomitant conditions 5, 6.
• Close monitoring of blood pressure and clinical status is essential to adjust the treatment approach as needed 6.