What is the management of hypertensive urgency?

From the Guidelines

Hypertensive urgency should be managed by reinstitution or intensification of antihypertensive drug therapy, without the need for immediate reduction in blood pressure or hospitalization, as stated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The management of hypertensive urgency involves a careful approach to avoid causing organ hypoperfusion due to rapid blood pressure reduction.

• The goal is to reduce blood pressure gradually over a period of hours to days, rather than minutes, to prevent potential complications.
• Oral medications such as amlodipine, labetalol, or captopril can be used to lower blood pressure, depending on the patient's comorbidities and other factors, as suggested by the guideline 1.
• It is essential to monitor patients closely with frequent blood pressure checks and symptom assessment to ensure that the blood pressure is being reduced at a safe rate.
• After initial control, establishing a long-term antihypertensive regimen is crucial to prevent future episodes of hypertensive urgency, and addressing underlying causes such as medication non-adherence, substance use, or secondary hypertension is also important.
• The guideline emphasizes that hypertensive urgencies are situations associated with severe blood pressure elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction, and therefore, do not require the same level of urgency as hypertensive emergencies 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Captopril tablets should be taken one hour before meals. Dosage must be individualized. Hypertension - Initiation of therapy requires consideration of recent antihypertensive drug treatment, the extent of blood pressure elevation, salt restriction, and other clinical circumstances For patients with severe hypertension (e.g., accelerated or malignant hypertension), when temporary discontinuation of current antihypertensive therapy is not practical or desirable, or when prompt titration to more normotensive blood pressure levels is indicated, diuretic should be continued but other current antihypertensive medication stopped and captopril dosage promptly initiated at 25 mg bid or tid, under close medical supervision

The management of hypertensive urgency may involve the use of captopril or other antihypertensive agents.

• The initial dose of captopril is 25 mg bid or tid, which may be increased as needed and tolerated.
• Captopril should be used under close medical supervision, especially in patients with severe hypertension.
• The use of a diuretic may also be beneficial in conjunction with captopril therapy 2.
• Labetalol may also be used in the management of hypertension, alone or in combination with other antihypertensive agents 3.

From the Research

Management of Hypertensive Urgency

• Hypertensive urgency is defined as a severe elevation in blood pressure, higher than 180/120 mmHg, without evidence of new or worsening organ damage 4.
• The management of hypertensive urgency involves a gradual lowering of blood pressure over 24-48 hours with oral medication, and aggressive blood pressure lowering should be avoided 4, 5.
• Oral agents such as clonidine, nifedipine, captopril, labetalol, prazosin, and nimodipine have been shown to be effective in managing hypertensive urgencies 5, 6, 7.

Choice of Medication

• The choice of specific medication depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities 4.
• Medications such as sodium nitroprusside, labetalol, esmolol, fenoldopam, and nicardipine are typically used for hypertensive emergencies, but may not be suitable for hypertensive urgencies due to their rapid onset and potential for significant hemodynamic complications 5, 8, 6.

Goals of Treatment

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 8.
• For hypertensive emergencies, a maximum blood pressure reduction of 20-25% within the first hour and then to 160/110-100 over the next 2-6 hours is considered appropriate, with a further gradual decrease over the next 24-48 hours to reach normal blood pressure levels 4.
• For hypertensive urgencies, the goal is to gradually lower blood pressure over 24-48 hours without causing significant hemodynamic complications 4, 5.