What is the management of hypertensive urgency (high blood pressure emergency)?

From the Guidelines

Hypertensive urgency should be managed with prompt but not immediate blood pressure reduction over 24-48 hours, using oral antihypertensive medications, with the goal of lowering blood pressure by no more than 25% in the first day to avoid organ hypoperfusion, as recommended by the most recent guidelines 1. The management of hypertensive urgency involves a careful approach to reduce blood pressure without causing organ hypoperfusion.

• The goal is to lower blood pressure by no more than 25% in the first day, which can be achieved with oral antihypertensive medications such as labetalol 200-400mg orally, amlodipine 5-10mg daily, or captopril 25mg 1.
• Patients should be monitored closely with frequent blood pressure checks and can typically be managed in an outpatient setting if they have no signs of end-organ damage.
• After initial control, establishing a long-term antihypertensive regimen, often requiring combination therapy, is crucial for ongoing management.
• Lifestyle modifications, including sodium restriction, weight loss, regular exercise, and limiting alcohol consumption, are essential components of ongoing management.
• It is also important to identify and address common triggers of hypertensive urgency, such as medication non-adherence, pain, anxiety, or substances like cocaine or amphetamines, to prevent recurrence. The distinction between hypertensive urgency and hypertensive emergency is critical, as the latter requires immediate blood pressure reduction and hospitalization, whereas hypertensive urgency can be managed in an outpatient setting with careful monitoring and oral antihypertensive medications, as supported by the latest guidelines 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 If possible, discontinue the patient’s previous antihypertensive drug regimen for one week before starting captopril. 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 (high blood pressure emergency) may involve:

• Initiating captopril therapy at 25 mg bid or tid under close medical supervision
• Continuing diuretic therapy if already being used
• Stopping other current antihypertensive medications if necessary
• Promptly titrating the dose of captopril every 24 hours or less until a satisfactory blood pressure response is obtained or the maximum dose is reached 2 Note that labetalol is indicated for the management of hypertension, but the provided label does not specifically address the management of hypertensive urgency 3

From the Research

Definition and Classification

• Hypertensive urgencies-emergencies are defined as a severe elevation in BP, higher than 180/120 mmHg, associated or not with the evidence of new or worsening organ damage for emergencies and urgencies respectively 4
• Hypertensive crises may be divided into hypertensive emergencies and hypertensive urgencies, with the presence or absence of target organ damage being the distinguishing factor 5, 6, 7

Management of Hypertensive Emergencies

• Immediate reduction in blood pressure is required in patients with acute end-organ damage, using a titratable, short-acting, intravenous antihypertensive agent 6
• A maximum BP 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 BP levels 4
• Rapid-acting intravenous antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside, although sodium nitroprusside is considered extremely toxic and its use should be avoided 6

Management of Hypertensive Urgencies

• Severe hypertension without acute end-organ damage is usually treated with oral antihypertensive agents 6
• A gradual lowering of BP over 24-48 hours with an oral medication is the best approach, and an aggressive BP lowering should be avoided 4
• Oral agents used in the treatment of urgent hypertension include clonidine, nifedipine, captopril, and minoxidil, although nifedipine and hydralazine are not recommended as first-line therapies due to significant toxicities and/or adverse effects 5, 6, 8

Treatment Goals

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 6
• Appropriate identification, evaluation, and treatment of these conditions are of great importance in the emergency department to prevent progression of organ damage and death 7