From the Guidelines
Hypertensive urgency requires prompt but not immediate treatment to lower blood pressure safely over 24-48 hours. For patients with hypertensive urgency, oral medications are preferred, with labetalol 200-400mg, captopril 25-50mg, or amlodipine 5-10mg being good initial choices 1. The goal is to reduce blood pressure by no more than 25% in the first 24 hours to avoid organ hypoperfusion.
Key Considerations
- Patients with hypertensive urgency do not have acute end-organ damage, but have severely elevated blood pressure (typically >180/120 mmHg) 1.
- Rapid blood pressure reduction should be avoided as it can lead to cerebral, cardiac, or renal hypoperfusion, especially in chronically hypertensive patients whose autoregulation is adapted to higher pressures 1.
- After initial treatment, patients should be monitored for 3-6 hours to ensure blood pressure is decreasing appropriately without complications.
- Underlying causes such as medication non-adherence, pain, anxiety, or substance use should be addressed.
- Patients should follow up within a week to adjust their antihypertensive regimen for long-term control.
Treatment Approach
- Oral medications are the preferred initial treatment for hypertensive urgency 1.
- The choice of oral medication should be based on the patient's clinical profile and comorbidities.
- Intravenous medications may be considered in patients who do not respond to oral therapy or have severe symptoms.
Monitoring and Follow-up
- Patients should be monitored closely for signs of organ hypoperfusion or other complications.
- Follow-up appointments should be scheduled to adjust the antihypertensive regimen and ensure long-term blood pressure control.
From the FDA Drug Label
Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. The answer to Hypertensive urgency is that sodium nitroprusside (IV) can be used for the immediate reduction of blood pressure in hypertensive crises, which may include hypertensive urgency.
- Key points:
- Sodium nitroprusside is indicated for hypertensive crises.
- Concomitant longer-acting antihypertensive medication should be administered.
- The duration of treatment with sodium nitroprusside should be minimized 2.
Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg The answer to Hypertensive urgency is that labetalol (IV) can be used to lower blood pressure.
- Key points:
- Labetalol HCl can be administered as a continuous intravenous infusion to lower blood pressure.
- The mean dose is 136 mg over 2-3 hours.
- Blood pressure is lowered by an average of 60/35 mmHg 3.
From the Research
Definition and Classification of Hypertensive Urgency
- Hypertensive urgency is defined as a severe elevation in blood pressure without evidence of end-organ injury 4, 5, 6
- It is classified as either urgency or emergency, depending on the presence of acute target-organ damage 5, 7
Management of Hypertensive Urgency
- In hypertensive urgency, blood pressure should be lowered gradually over 24 to 48 hours using oral antihypertensives 4, 6
- The choice of specific drugs depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities 6
- Oral agents such as clonidine, nifedipine, captopril, and labetalol have been shown to be effective in managing hypertensive urgencies 4, 5, 8
Key Considerations in Managing Hypertensive Urgency
- Rapid uncontrolled pressure reduction may be harmful, and therefore, blood pressure should be lowered gradually 4
- The efficacy of available treatments appears similar, but the underlying pathophysiological and clinical findings, mechanism of action, and potential for adverse effects should guide the choice of treatment 4
- Factors that may precipitate a hypertensive crisis, such as renovascular hypertension, acute glomerulonephritis, and eclampsia, should be considered when managing hypertensive urgency 5
Comparison with Hypertensive Emergency
- Hypertensive emergency requires immediate blood pressure reduction to avoid further end-organ damage, whereas hypertensive urgency does not require immediate reduction 4, 5, 6
- The management of hypertensive emergency typically involves intravenous antihypertensive agents, whereas hypertensive urgency can usually be managed with oral agents 4, 5, 8