What is the distinction between hypertensive emergency and hypertensive urgency?

From the Guidelines

Hypertensive emergency is defined as severely elevated blood pressure (typically >180/120 mmHg) WITH evidence of acute target organ damage, whereas hypertensive urgency involves severely elevated blood pressure WITHOUT acute target organ damage. The management of these two conditions differs significantly, with hypertensive emergencies requiring immediate blood pressure reduction (within minutes to hours) with intravenous medications in an intensive care setting, as recommended by the European Heart Journal in 2019 1. In contrast, hypertensive urgency allows for more gradual blood pressure reduction over 24-48 hours using oral medications. The distinction between these two conditions is critical, as overly rapid blood pressure reduction in hypertensive urgency can cause harm through cerebral hypoperfusion, while delayed treatment in hypertensive emergency can result in permanent organ damage or death, as highlighted in the 2018 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. Some key points to consider in the management of hypertensive emergencies include:

• The use of intravenous medications such as labetalol, nicardipine, or clevidipine in an intensive care setting
• The importance of close hemodynamic monitoring
• The need for a controlled blood pressure reduction to prevent further hypertensive damage
• The consideration of the clinical context, including the type of target organ damage and the presence of any compelling conditions, as outlined in the European Heart Journal in 2019 1. Overall, the management of hypertensive emergencies and urgencies requires a careful and nuanced approach, taking into account the individual patient's clinical presentation and the potential risks and benefits of different treatment strategies.

From the Research

Definition of Hypertensive Emergency vs Urgency

• Hypertensive emergency is a condition characterized by elevated blood pressure with the presence of acute target organ disease, requiring immediate treatment to prevent or minimize end-organ damage 2, 3, 4.
• Hypertensive urgency, on the other hand, is a condition where blood pressure is elevated without the presence of acute target organ disease, and does not require immediate normalization of blood pressure 2, 3, 5.

Key Differences

• The presence of acute target organ disease is the key distinguishing feature between hypertensive emergency and urgency 2, 3.
• Hypertensive emergencies require rapid controlled reduction of blood pressure, usually with parenteral drugs, to prevent or minimize end-organ damage 6, 2, 4.
• Hypertensive urgencies can usually be managed with oral agents, and the goal is to reduce blood pressure gradually over a period of hours 2, 3, 5.

Treatment Approaches

• Hypertensive emergencies are typically treated with intravenous antihypertensive agents, such as sodium nitroprusside, nitroglycerin, and hydralazine, which have a rapid onset of action and can be titrated to achieve the desired blood pressure reduction 6, 2, 4.
• Hypertensive urgencies can be treated with oral agents, such as nifedipine, nicardipine, and captopril, which have a slower onset of action and can be used to gradually reduce blood pressure over a period of hours 2, 3, 5.