What is the initial workup and treatment for a patient presenting with hypertensive urgency?

From the Guidelines

The initial workup and treatment for a patient presenting with hypertensive urgency should focus on gradual blood pressure reduction over 24-48 hours with oral medications, as patients lacking acute hypertension-mediated end organ damage can be safely managed without intravenous therapy. The approach to hypertensive urgency involves a thorough assessment including vital signs, focused history, physical examination, and basic laboratory tests, as outlined in the management of hypertensive emergencies 1. Blood pressure should be confirmed with proper technique after the patient has rested for 5 minutes.

Key Considerations

• Treatment aims to gradually lower blood pressure over 24-48 hours, typically with oral medications, to avoid the risks associated with too-rapid reduction, which can lead to ischemic events in vital organs.
• First-line options include labetalol, captopril, or amlodipine, with the goal of reducing blood pressure by no more than 25% in the first 24 hours.
• Patients should be monitored for 3-6 hours after initial treatment to ensure blood pressure is responding appropriately without dropping too rapidly.
• Underlying causes should be addressed, and patients should be educated about medication adherence, lifestyle modifications, and follow-up care within 1-7 days, as suggested by the 2020 international society of hypertension global hypertension practice guidelines 1.

Management Principles

• The choice of antihypertensive treatment is determined by the clinical presentation and the absence of acute hypertension-mediated end organ damage.
• Patients with substantially elevated BP who lack acute end organ damage are not considered a hypertensive emergency and can typically be treated with oral antihypertensive therapy 1.
• The management approach should balance the need to control elevated blood pressure while avoiding the risks associated with too-rapid reduction.

From the Research

Initial Workup for Hypertensive Urgency

• The initial workup for a patient presenting with hypertensive urgency involves obtaining a full medical and medication history to guide treatment 2
• Recognition of hypertensive crisis at initial assessment is crucial, and it is essential to differentiate between hypertensive urgency and hypertensive emergency based on the presence or absence of target organ damage (TOD) 2, 3
• Patients with hypertensive urgency do not exhibit TOD, which is seen only in hypertensive emergencies and can involve the heart, kidneys, or brain 2

Treatment of Hypertensive Urgency

• Blood pressure should be lowered within 24 to 48 hours to avoid hypertensive target organ damage 4
• Oral antihypertensive therapy is usually sufficient, and hospitalization is not required in most cases 4, 5
• Initiation or reestablishment of long-acting oral antihypertensive medications, addressing medication nonadherence, and reviewing precipitating factors are essential in the treatment of hypertensive urgency 5
• Proper and effective treatment involves the appropriate use of specific agents based on knowledge of any comorbid disease state 2

Laboratory Tests

• While there is no direct evidence on specific laboratory tests for hypertensive urgency, it is essential to note that elevations in blood urea nitrogen and/or serum creatinine do not necessarily indicate structural renal disease, and their interpretation should be done with awareness of extrarenal factors that can affect them 6