From the Guidelines
Management of hypertensive urgency involves gradual blood pressure reduction over 24-48 hours using oral medications, as recommended by the most recent guidelines. The approach to managing hypertensive urgency is to restart or intensify the patient's existing antihypertensive regimen, or initiate new oral medications such as captopril 25mg, labetalol 200-400mg, or amlodipine 5-10mg 1.
Key Considerations
- Blood pressure should be lowered by no more than 25% within the first few hours, then gradually to normal levels over the following day.
- Patients should be monitored for 3-6 hours after initial treatment to ensure blood pressure is responding appropriately without complications.
- Most patients can be managed in an outpatient setting with close follow-up within 24-72 hours.
- It's essential to distinguish hypertensive urgency (severely elevated blood pressure without acute end-organ damage) from hypertensive emergency, which requires immediate IV therapy in an intensive care setting due to ongoing organ damage, as stated in the European Heart Journal 1.
Treatment Approach
- The selection of an antihypertensive agent should be based on the drug’s pharmacology, pathophysiological factors underlying the patient’s hypertension, degree of progression of target organ damage, the desirable rate of BP decline, and the patient's overall clinical condition 1.
- Continuous infusion of short-acting titratable antihypertensive agents is often preferable to prevent further target organ damage in hypertensive emergencies, but this is not typically necessary for hypertensive urgency 1.
From the FDA Drug Label
The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. 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. In patients with severe or postoperative hypertension, nicardipine hydrochloride injection (5 to 15 mg/hr) produced dose-dependent decreases in blood pressure.
The recommended management for hypertensive urgency involves administering nicardipine hydrochloride injection by slow continuous infusion.
- The initial rate of infusion is 5 mg/hr, which can be increased by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr until the desired blood pressure reduction is achieved.
- In cases of severe hypertension, infusion rates of 5 to 15 mg/hr have been used to produce dose-dependent decreases in blood pressure.
- Labetalol (IV) can also be used for the management of hypertensive urgency, with an initial dose of 0.25 mg/kg followed by additional doses of 0.5 mg/kg at 15-minute intervals, up to a total cumulative dose of 1.75 mg/kg.
- The choice of medication and infusion rate should be individualized based on the patient's specific needs and medical condition, and should be titrated to achieve the desired blood pressure reduction while minimizing the risk of adverse effects 2, 2, 3.
From the Research
Management of Hypertensive Urgency
The management of hypertensive urgency involves the use of oral antihypertensive agents to safely reduce blood pressure, as immediate reduction is not required in the absence of acute end-organ damage 4, 5, 6.
- The primary goal of intervention is to safely reduce blood pressure, with the appropriate therapeutic approach depending on the patient's clinical presentation 4, 6.
- Oral antihypertensive agents are usually sufficient for treating hypertensive urgency, whereas patients with hypertensive emergencies require immediate reduction in blood pressure with intravenous antihypertensive agents in an intensive care unit setting 4, 5, 6.
- Rapid-acting intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine, are available for the management of hypertensive crises, with newer agents offering considerable advantages over older ones 4, 5, 6, 7.
- Certain medications, including sodium nitroprusside, nifedipine, nitroglycerin, and hydralazine, should be avoided or used with caution due to their potential toxicities and side effects 4, 5, 6, 7.
Treatment Options
Some treatment options for hypertensive urgency include: