What is the full inpatient management of hypertensive urgency?

Inpatient Management of Hypertensive Urgency

For hypertensive urgency (BP >180/120 mmHg without target organ damage), the recommended management is oral antihypertensive medication with gradual blood pressure reduction over 24-48 hours rather than immediate aggressive treatment. 1

Definition and Initial Assessment

Hypertensive urgency is defined as:

• Blood pressure >180/120 mmHg
• Absence of target organ damage
• Does not require immediate aggressive treatment 1, 2

Key assessment points:

• Confirm elevated BP with multiple measurements
• Distinguish from hypertensive emergency by assessing for target organ damage:
  • Neurological: Altered mental status, focal deficits
  • Cardiovascular: Chest pain, pulmonary edema, heart failure
  • Renal: Acute kidney injury
  • Ophthalmologic: Papilledema, retinal hemorrhages

Treatment Approach

Blood Pressure Reduction Goals

• Initial reduction: No more than 25% of mean arterial pressure within the first hour 3
• Secondary target: 160/100-110 mmHg within the next 2-6 hours 3
• Final target: Gradual normalization over 24-48 hours if stable 3

First-Line Medications

1. Oral labetalol: 200-400 mg PO every 2-3 hours as needed 3, 4

   • Advantages: Combined alpha and beta blockade, effective BP reduction
   • Contraindications: Asthma, COPD, heart block, severe bradycardia

2. Oral captopril: 25 mg PO every 1-2 hours as needed 5

   • Advantages: Rapid onset (15-30 minutes)
   • Contraindications: Pregnancy, bilateral renal artery stenosis, hyperkalemia

Alternative Medications

• Oral clonidine: 0.1-0.2 mg initially, followed by 0.1 mg every hour until target BP is reached (max 0.8 mg)
• Oral amlodipine: 5-10 mg once daily

Monitoring Protocol

• Continuous vital sign monitoring every 15-30 minutes until stable
• Avoid excessive BP reduction which can lead to organ hypoperfusion
• Monitor for symptoms of hypotension (dizziness, syncope)
• Monitor for medication side effects

Important Considerations and Pitfalls

Common Pitfalls to Avoid

1. Overly aggressive BP reduction: Rapid reduction can lead to cerebral, cardiac, or renal hypoperfusion 3
2. Misclassification: Incorrectly treating a hypertensive emergency as an urgency
3. Using short-acting nifedipine: Avoid sublingual/oral nifedipine due to risk of precipitous BP drops 3
4. Discharging patients too early: Ensure BP is stable before discharge

Special Populations

• Elderly: Start with lower doses due to increased sensitivity to medications
• Renal impairment: Adjust medication doses; captopril requires dose reduction
• Pregnancy: Labetalol is preferred; avoid ACE inhibitors 3
• Cocaine-induced hypertension: Avoid beta-blockers; use labetalol (alpha and beta effects) or calcium channel blockers 3

Transition of Care and Follow-up

• Ensure follow-up within 7 days after discharge 1
• Provide patient education on medication adherence and lifestyle modifications
• Adjust outpatient antihypertensive regimen as needed
• Consider 24-hour ambulatory BP monitoring to assess BP control

Prognosis

• Patients with hypertensive urgencies have higher cardiovascular risk than those without 3
• Proper management reduces risk of progression to hypertensive emergency
• Long-term BP control is essential to prevent recurrence and complications

Remember that hypertensive urgency, while requiring prompt attention, does not necessitate the same immediate aggressive treatment as hypertensive emergency. The goal is controlled reduction of blood pressure over 24-48 hours to prevent organ damage from excessive BP reduction.