What is the initial treatment for hypertension (Htn) urgency?

Management of Hypertensive Urgency

For hypertensive urgency (severe BP elevation >180/120 mmHg without evidence of target organ damage), the initial treatment is oral antihypertensive medication with gradual blood pressure reduction over 24-48 hours, not rapid reduction. 1, 2

Definition and Differentiation

• Hypertensive urgency: Severe BP elevation (>180/120 mmHg) WITHOUT evidence of new or worsening target organ damage
• Hypertensive emergency: Severe BP elevation WITH evidence of new or worsening target organ damage (requires immediate hospitalization and IV medications)

Initial Treatment Approach

1. Oral antihypertensive medication is the recommended first-line treatment for hypertensive urgency 1

   • Reinstitute or intensify existing oral antihypertensive therapy
   • Avoid short-acting nifedipine due to risk of precipitous BP decline 2, 1

2. Blood pressure reduction goals:

   • Reduce BP by no more than 25% within the first hour
   • Then, if stable, aim for 160/100 mmHg within the next 2-6 hours
   • Cautiously reduce to normal during the following 24-48 hours 2, 1

Medication Options

1. First-line oral medications:

   • ACE inhibitors (e.g., lisinopril 10-20 mg) 3
   • Calcium channel blockers (e.g., amlodipine 5-10 mg) 4
   • Combination therapy may be appropriate based on patient's existing regimen

2. Medication selection considerations:

   • For patients already on antihypertensive therapy: Optimize current regimen
   • For new patients: Consider starting with an ACE inhibitor or ARB plus a calcium channel blocker or thiazide diuretic 1
   • For patients with volume overload: Add a diuretic 1

Monitoring and Follow-up

• Monitor vital signs, especially blood pressure every 30 minutes during the first 2 hours 1
• Schedule follow-up within 24 hours to prevent undetected progression to hypertensive emergency 1
• Continue with monthly follow-up visits until target blood pressure is reached 1

Important Cautions

• Avoid excessive BP reduction which can lead to organ hypoperfusion 1
• Excessive falls in pressure may precipitate renal, cerebral, or coronary ischemia 2
• Patients should be monitored for at least several hours to ensure stability before discharge 1
• Investigate for secondary causes of hypertension, especially in recurrent cases 1

Special Considerations

• Address medication adherence issues, as non-compliance is a common cause of hypertensive urgency 1
• Screen for substance use (amphetamines, cocaine) which may trigger hypertensive crisis 1
• Consider outpatient management only if reliable follow-up is assured; otherwise, consider extended observation (4-6 hours) in an emergency setting 2

Hypertensive urgency, while serious, does not require the same aggressive approach as hypertensive emergency. The focus should be on gradual, controlled blood pressure reduction with oral medications while ensuring appropriate follow-up to monitor for complications and achieve long-term blood pressure control.