Difference Between Hypertensive Urgency and Emergency
The key difference between hypertensive urgency and hypertensive emergency is that hypertensive emergency involves acute target organ damage, while hypertensive urgency is severe blood pressure elevation without evidence of acute target organ damage. 1
Definitions and Diagnostic Criteria
Hypertensive Emergency
- Blood pressure >180/120 mmHg WITH evidence of acute target organ damage 1
- Requires immediate blood pressure reduction (within hours) in an intensive care setting 1, 2
- Associated with high mortality (>79% one-year mortality rate if untreated) 1
Hypertensive Urgency
- Blood pressure >180/110 mmHg WITHOUT evidence of acute target organ damage 1
- Can be managed with oral medications and typically does not require hospitalization 1, 3
- Blood pressure should be lowered gradually within 24-48 hours 3
Clinical Presentation and Assessment
Target Organ Damage to Evaluate (for Emergency)
- Neurological: Hypertensive encephalopathy, stroke (ischemic or hemorrhagic)
- Cardiac: Acute coronary syndrome, cardiogenic pulmonary edema, aortic dissection
- Renal: Acute kidney injury, hematuria, proteinuria
- Ophthalmologic: Retinal hemorrhages, exudates, papilledema 1
Diagnostic Workup
- Confirm elevated BP with proper technique and appropriate cuff size
- Perform fundoscopic examination
- Basic metabolic panel, urinalysis, electrocardiogram
- Consider chest X-ray if respiratory symptoms are present 1
Management Approaches
Hypertensive Emergency
- Immediate treatment goal: Reduce mean arterial pressure by 20-25% within the first hour, not immediate normalization 1
- Setting: Intensive care unit with continuous BP monitoring 4
- Medication approach: Short-acting titratable IV antihypertensive medications 1, 4
- First-line IV medications:
- Nicardipine: 5 mg/h IV, increase by 2.5 mg/h every 5 minutes, maximum 15 mg/h
- Clevidipine: 1-2 mg/h IV, double dose every 90 seconds initially
- Labetalol: 0.3-1.0 mg/kg IV (maximum 20 mg)
- Esmolol: 0.5-1 mg/kg IV bolus 1
Hypertensive Urgency
- Treatment goal: Lower BP within 24-48 hours 3
- Setting: Typically outpatient management 1, 3
- Medication approach: Oral antihypertensive medications 3
- First-line oral options: Captopril, labetalol, amlodipine, clonidine 1
- Ensure follow-up care is arranged 3
Condition-Specific Considerations
Specific Blood Pressure Targets for Emergencies
- Aortic dissection: <120 mmHg systolic within the first hour
- Severe preeclampsia/eclampsia: <140 mmHg systolic within the first hour
- Hypertensive encephalopathy: Reduce mean arterial pressure by 20-25% immediately
- Acute ischemic stroke with BP >220/120 mmHg: Reduce mean arterial pressure by 15% within the first hour
- Acute hemorrhagic stroke with BP >180 mmHg: 130-180 mmHg systolic immediately 1
Common Pitfalls and Caveats
- Avoid rapid BP reduction: Excessive lowering of blood pressure can lead to cerebral hypoperfusion, especially in patients with chronic hypertension who have altered cerebral autoregulation 2
- Avoid certain medications: Hydralazine, immediate-release nifedipine, and nitroglycerin should be avoided in general hypertensive emergencies 4
- Sodium nitroprusside caution: Use with caution due to risk of cyanide toxicity 1, 4
- Monitoring requirements: Patients with hypertensive emergencies require continuous BP monitoring, preferably with arterial line 4
- Follow-up importance: Patients with hypertensive urgency have a 5-fold higher risk of uncontrolled BP during follow-up and require close monitoring 1
Long-term Considerations
- Implement lifestyle modifications for all patients (weight management, physical activity, smoking cessation, moderate alcohol consumption) 1
- Patients presenting with hypertensive urgency often have worse cardiovascular risk profiles and require adjustment of their antihypertensive regimen 1
- Untreated accelerated/malignant hypertension has extremely poor prognosis 1