What is the definition of hypertensive urgency?

Definition of Hypertensive Urgency

Hypertensive urgency is defined as blood pressure (BP) >180/110 mmHg without evidence of acute target organ damage. 1

Distinguishing Hypertensive Urgency from Emergency

Hypertensive urgency is fundamentally a diagnosis of exclusion, characterized by:

• Severely elevated blood pressure (typically >180/110 mmHg)
• Absence of acute hypertension-mediated target organ damage
• May present with non-specific symptoms such as headache, malaise, and general feeling of illness 2, 3

This is in contrast to hypertensive emergency, which is defined by:

• Severely elevated blood pressure (>180/120 mmHg)
• Presence of acute target organ damage affecting key organs:
  • Heart (acute coronary syndrome, left ventricular failure with pulmonary edema)
  • Brain (hypertensive encephalopathy, stroke, intracranial hemorrhage)
  • Kidneys (acute renal failure)
  • Large arteries (aortic dissection)
  • Retina (advanced retinopathy with hemorrhages, exudates, or papilledema) 2, 1

Clinical Approach to Suspected Hypertensive Urgency

When evaluating a patient with severely elevated blood pressure:

1. Confirm the elevated BP:

   • Repeat measurements in both arms after 5-10 minutes of rest
   • Use appropriate cuff size and proper technique 1

2. Evaluate for target organ damage:

   • Physical examination including neurological status and fundoscopic exam
   • Basic diagnostic tests: electrocardiogram, basic metabolic panel, urinalysis
   • Consider chest X-ray if respiratory symptoms are present 1

3. Review medication adherence:

   • Determine if the patient has missed doses of antihypertensive medications
   • Check for use of medications that can elevate BP (NSAIDs, decongestants) 1

Management of Hypertensive Urgency

The goal of management is to reduce BP by approximately 15% within the first 24 hours, not immediate normalization 1, 3:

• Place the patient in a quiet environment
• Monitor BP frequently (every 30 minutes for first 2 hours, every hour for next 4 hours)
• Use oral antihypertensive medications, with choice based on comorbidities:
  • First-line options: captopril, labetalol, amlodipine, clonidine 1

Common Pitfalls to Avoid

1. Excessive BP lowering: Aim for 10-15% reduction over 24 hours, not normalization, to avoid complications from cerebral hypoperfusion 1, 3

2. Failure to distinguish urgency from emergency: Careful assessment for target organ damage is essential 1

3. Neglecting medication reconciliation: Identifying if missed doses or medication interactions are contributing factors is crucial 1

4. Inappropriate use of rapid-acting agents: Medications such as immediate-release nifedipine should be avoided due to risk of excessive BP reduction 4, 5

Long-term Considerations

Patients presenting with hypertensive urgency:

• Have a 5-fold higher risk of uncontrolled BP during follow-up 6
• Often have worse cardiovascular risk profiles 6
• Require close follow-up and adjustment of antihypertensive regimen
• Should implement lifestyle modifications (weight management, physical activity, smoking cessation) 1

Hypertensive urgency represents a significant clinical challenge that requires careful evaluation to exclude hypertensive emergency, followed by controlled blood pressure reduction over 24-48 hours rather than rapid normalization.