What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

For hypertensive urgency (severe hypertension >180/120 mmHg without evidence of acute target organ damage), oral antihypertensive medications should be used with gradual blood pressure reduction over 24-48 hours, avoiding rapid decreases that could lead to organ hypoperfusion. 1

Definition and Assessment

Hypertensive urgency is defined as:

• Severely elevated blood pressure (typically >180/120 mmHg)
• Without evidence of acute target organ damage
• Distinguished from hypertensive emergency, which involves acute organ damage requiring immediate intervention

Initial Assessment

• Confirm blood pressure readings with repeated measurements in both arms
• Perform targeted evaluation to rule out end-organ damage:
  • Physical examination including fundoscopic exam
  • Basic laboratory tests: renal panel, urinalysis
  • Electrocardiogram
  • Additional testing (echocardiogram, neuroimaging, chest CT) only if symptoms suggest organ involvement 2

Treatment Approach

Blood Pressure Reduction Goals

• Reduce BP by no more than 25% within the first hour
• Then, if stable, aim for 160/100 mmHg within the next 2-6 hours
• Gradually normalize BP over the following 24-48 hours 2, 1

Medication Selection

First-line oral medications:

• Labetalol: Initial dose 200-400 mg orally
• Captopril: 25-50 mg sublingually (onset within 10 minutes)
• Clonidine: 0.1-0.2 mg orally, with hourly doses of 0.05-0.1 mg until target BP is achieved 1

Important cautions:

• Avoid short-acting nifedipine due to risk of unpredictable BP drops and potential for cerebral, coronary, or renal hypoperfusion 1
• Most patients can be managed in an outpatient setting with oral medications and close follow-up 2
• For patients already on antihypertensive therapy, consider restarting or intensifying their existing regimen 1

Special Considerations

Patient-specific factors:

• Elderly patients: Consider more gradual BP reduction to avoid hypoperfusion
• Stroke patients: Generally withhold BP-lowering unless BP >220/120 mmHg
• Patients with sympathomimetic use (methamphetamine, cocaine): Use caution with beta-blockers 1

Setting of Care

• Most hypertensive urgencies can be managed in outpatient settings
• No evidence supports routine hospital admission for hypertensive urgency without other indications 2
• Arrange follow-up within 24-72 hours to ensure adequate BP control 1

Long-term Management

After initial control of hypertensive urgency:

1. Initiate or adjust maintenance therapy once BP is stabilized
2. Consider combination therapy for long-term control
3. Preferred regimens include:
   • RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or thiazide-like diuretic
   • Target BP of 120-129 mmHg systolic for most adults 1
4. Address medication adherence issues, which are common precipitants of hypertensive urgency

Pitfalls to Avoid

• Rapid BP reduction causing hypoperfusion of vital organs
• Using short-acting nifedipine, which can cause unpredictable BP drops
• Failing to distinguish between hypertensive urgency and emergency
• Neglecting to arrange timely follow-up after initial treatment
• Overlooking potential secondary causes of severe hypertension 2, 1

By following this approach, hypertensive urgency can be safely managed while minimizing the risk of adverse outcomes related to either uncontrolled hypertension or excessive BP reduction.