From the Guidelines
Hypertensive urgency should be treated by reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable, without the need for immediate reduction in blood pressure or hospitalization. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, hypertensive urgencies are situations associated with severe blood pressure elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction.
Key Considerations
- Many patients with hypertensive urgency have withdrawn from or are noncompliant with antihypertensive therapy and do not have clinical or laboratory evidence of acute target organ damage 1.
- The goal is to gradually lower blood pressure over a period of time, rather than rapid reduction, which can cause organ damage.
- First-line medications for hypertensive urgency are not explicitly stated in the guideline, but common practice includes the use of oral medications such as captopril, labetalol, or amlodipine.
Management Approach
- Blood pressure should be monitored regularly, with a goal of reducing it to a safe level over 24-48 hours.
- Patients should be evaluated for target organ damage through basic labs and an ECG.
- Underlying causes should be addressed, including medication non-adherence, pain, or anxiety.
- Most patients can be managed in an outpatient setting with close follow-up within 24-72 hours, unless there are signs of target organ damage, in which case the condition should be treated as a hypertensive emergency requiring immediate hospitalization 1.
From the FDA Drug Label
Nicardipine hydrochloride injection is indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable. For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved. The mean time to therapeutic response for severe hypertension, defined as diastolic blood pressure less than or equal to 95 mmHg or greater or equal to 25 mmHg decrease and systolic blood pressure less than or equal to 160 mmHg, was 77 ± 5 minutes.
The treatment guidelines for hypertensive urgency with nicardipine (IV) involve:
- Initiating therapy at a rate of 5 mg/hr for a gradual reduction in blood pressure
- Increasing the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr until desired blood pressure reduction is achieved
- Achieving therapeutic response for severe hypertension in approximately 77 minutes on average, with an average maintenance dose of 8.0 mg/hr 2
From the Research
Hypertensive Urgency Treatment Guidelines
- Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease 3.
- The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, and the appropriate therapeutic approach will depend on the patient's clinical presentation 4.
- Hypertensive urgencies can usually be managed with oral agents, such as:
- A study comparing clonidine and captopril in patients with hypertensive urgency found that clonidine relieved symptoms faster and had fewer side effects 6.
- Agent selection should be based on the perceived need for urgent blood pressure control, the cause of hypertensive urgency, and concomitant conditions 5.
- Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages over other available agents in the management of hypertensive crises 4, 7.
- Sodium nitroprusside, nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to their potential adverse effects and difficulties in use 4, 7.