What is the treatment approach for hypertensive emergency vs hypertensive urgency?

Hypertensive Emergency vs Urgency: Treatment Approach

Hypertensive emergencies require immediate blood pressure reduction with intravenous medications in an intensive care setting, while hypertensive urgencies can be managed with oral medications and close outpatient follow-up. 1

Definitions and Differentiation

• Hypertensive Emergency: Severe BP elevation (typically >180/120 mmHg) with evidence of acute target organ damage to the heart, brain, kidneys, retina, or large arteries 2
• Hypertensive Urgency: Severe BP elevation without evidence of acute target organ damage 2

Approach to Hypertensive Emergency

Initial Management

• Admit to Intensive Care Unit for continuous BP monitoring 2
• Use parenteral (IV) antihypertensive agents with careful titration 2
• Reduce BP by no more than 25% within the first hour, then aim for 160/100 mmHg within 2-6 hours, with gradual normalization over 24-48 hours 1

Medication Selection for Hypertensive Emergency

1. First-line IV medications:

   • Nicardipine: 5-15 mg/h IV, onset 5-10 min, duration 15-30 min 2, 3
   • Labetalol: 20-80 mg IV bolus every 10 min, onset 5-10 min, duration 3-6 h 2, 1
   • Fenoldopam: 0.1-0.3 μg/kg/min IV infusion, onset 5 min, duration 30 min 2

2. Condition-specific recommendations:

   • Aortic dissection: Labetalol or esmolol with target SBP <120 mmHg 1
   • Pulmonary edema: Nitroglycerin (5-100 μg/min) or nitroprusside 2, 1
   • Eclampsia/preeclampsia: Hydralazine (10-20 mg IV) or labetalol 2, 1
   • Ischemic stroke: Generally avoid BP reduction unless >220/120 mmHg 1
   • Hemorrhagic stroke: Careful reduction to <180 mmHg if SBP ≥220 mmHg 1

Monitoring and Adjustments

• Continuous BP monitoring, preferably intra-arterial 4
• Adjust infusion rate as needed to maintain desired BP response 3
• Change infusion site every 12 hours if administered via peripheral vein 3
• Monitor closely in patients with cardiac, hepatic, or renal impairment 3

Approach to Hypertensive Urgency

Initial Management

• Confirm BP with repeated measurements in both arms 1
• Perform targeted evaluation to rule out end-organ damage (physical exam, basic labs, ECG) 1
• Outpatient management is appropriate for most patients 1

Medication Selection for Hypertensive Urgency

• Oral antihypertensive agents with gradual BP reduction over 24-48 hours 2, 1
• Recommended oral medications:
  • Captopril (25-50 mg)
  • Clonidine (0.1-0.2 mg)
  • Labetalol (oral formulation)

Important Cautions

• Avoid short-acting nifedipine due to risk of unpredictable BP drops and precipitating renal, cerebral, or coronary ischemia 2, 1, 4
• Avoid rapid BP reduction which can cause hypoperfusion of vital organs 1
• Avoid sodium nitroprusside when possible due to toxicity concerns 4

Follow-up and Transition to Maintenance Therapy

1. For hypertensive emergencies:

   • Transfer to oral antihypertensive agents once BP is stabilized 1
   • When switching to oral nicardipine, administer first dose 1 hour before discontinuing IV infusion 3

2. For hypertensive urgencies:

   • Arrange close follow-up within 24-72 hours 1
   • Adjust maintenance therapy considering combination therapy for long-term control 1
   • Address medication adherence issues, as non-adherence is a common precipitating factor 2

Common Pitfalls to Avoid

• Treating asymptomatic severe hypertension too aggressively 1
• Failing to recognize secondary causes of hypertensive crisis 2
• Using short-acting nifedipine or hydralazine for urgent BP control 2, 1
• Reducing BP too rapidly, especially in elderly patients or those with cerebrovascular disease 1
• Discharging patients without adequate follow-up arrangements 1