From the Guidelines
Hypertensive urgency and hypertensive emergency are distinct conditions that differ in their severity and management, with hypertensive emergency requiring immediate blood pressure reduction in an intensive care setting due to evidence of acute end-organ damage, whereas hypertensive urgency involves severely elevated blood pressure without evidence of acute end-organ damage and can be managed with oral medications within 24-48 hours. The key difference between the two conditions lies in the presence or absence of acute end-organ damage, such as encephalopathy, stroke, acute heart failure, aortic dissection, or acute kidney injury, which necessitates immediate attention and treatment in a hypertensive emergency 1.
Definition and Management
Hypertensive urgency is characterized by severely elevated blood pressure (typically >180/120 mmHg) without evidence of acute end-organ damage, and its management involves blood pressure reduction within 24-48 hours using oral medications like captopril, labetalol, or amlodipine 1. In contrast, hypertensive emergency requires immediate blood pressure reduction (within minutes to hours) in an intensive care setting using intravenous medications like labetalol, nicardipine, or clevidipine, due to the presence of acute end-organ damage 1.
Clinical Considerations
The presence of symptoms like severe headache, visual changes, chest pain, or neurological deficits should raise suspicion for end-organ damage and potential hypertensive emergency 1. Rapid and uncontrolled or excessive blood pressure lowering is not recommended in hypertensive emergency, as this can lead to further complications 1. The choice of antihypertensive treatment is predominantly determined by the type of organ damage, and low initial doses should be used because these patients can be very sensitive to these agents 1.
Key Recommendations
- Hypertensive emergency requires immediate blood pressure reduction in an intensive care setting using intravenous medications.
- Hypertensive urgency can be managed with oral medications within 24-48 hours.
- The presence of acute end-organ damage is the key distinguishing feature between hypertensive emergency and hypertensive urgency.
- Rapid and uncontrolled or excessive blood pressure lowering should be avoided in hypertensive emergency.
From the Research
Definition and Classification
- Hypertensive crisis is defined as a systolic blood pressure >180 mm Hg or a diastolic blood pressure >120 mm Hg 2, 3, 4.
- Hypertensive crisis can be further classified as a hypertensive urgency or hypertensive emergency depending on end-organ involvement, including cardiac, renal, and neurologic injury 2, 3, 5, 4.
Hypertensive Urgency
- Hypertensive urgency is characterized by severe hypertension with no or minimal end-organ damage 2, 3, 5, 4.
- Patients with hypertensive urgency may be treated with oral antihypertensives as an outpatient 2, 3, 4.
- The goal is to control blood pressure within 24 hours 5.
Hypertensive Emergency
- Hypertensive emergency is characterized by acute end-organ damage, such as cardiac, renal, or neurologic injury 2, 3, 5, 4.
- Patients with hypertensive emergency require immediate reduction of blood pressure with a short-acting titratable intravenous antihypertensive medication 2, 3, 4.
- Patients with hypertensive emergency are best treated in an intensive care unit (ICU) 2, 3, 4.
- The goal is to reduce blood pressure within one hour 5.
Treatment Options
- Rapid-acting intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine, are available for the treatment of hypertensive emergencies 2, 3, 4, 6.
- Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 3, 4, 6.
- Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to their significant toxicities and/or adverse effects 3, 4, 6.