What are the management strategies for hypertensive urgency and emergency?

Management of Hypertensive Urgency and Emergency

For hypertensive emergency (severe BP elevation with target organ damage), immediate hospitalization with IV medications is required, while hypertensive urgency (severe BP without organ damage) can be managed with oral medications and close follow-up. 1

Definitions and Clinical Assessment

• Hypertensive Emergency: Severe BP elevation (typically >180/120 mmHg) WITH evidence of acute target organ damage
• Hypertensive Urgency: Severe BP elevation WITHOUT evidence of new/worsening target organ damage

Key Assessment Points

• Evaluate for target organ damage:
  • Neurological: Encephalopathy, stroke (ischemic/hemorrhagic)
  • Cardiovascular: Acute coronary syndrome, pulmonary edema, heart failure
  • Renal: Acute kidney injury
  • Ophthalmologic: Retinopathy with papilledema
  • Vascular: Aortic dissection

Management of Hypertensive Emergency

Initial Approach

1. Immediate hospitalization in ICU/high dependency setting
2. IV medication with continuous BP monitoring
3. Target BP reduction: No more than 25% within first hour, then aim for 160/100 mmHg within 2-6 hours, with cautious reduction to normal over 24-48 hours 1

First-Line IV Medications

• Labetalol: 10 mg IV over 1-2 min, may repeat/double every 10-20 min to max 300 mg 1
• Nicardipine: Start at 5 mg/hr, titrate by 2.5 mg/hr every 15 min (max 15 mg/hr) 1, 2
• Clevidipine: Start at 2 mg/hr, titrate in 2-fold increments at 3-minute intervals 3

Condition-Specific Management

Clinical Presentation	Target BP	First-Line Treatment	Alternative
Malignant HTN with/without renal failure	MAP -20-25% over hours	Labetalol	Nitroprusside, Nicardipine
Hypertensive encephalopathy	MAP -20-25% immediately	Labetalol	Nitroprusside, Nicardipine
Acute ischemic stroke, BP >220/120	MAP -15% over 1 hour	Labetalol	Nicardipine
Acute hemorrhagic stroke, SBP >180	SBP 130-180 immediately	Labetalol	Nicardipine
Acute coronary event	SBP <140 immediately	Nitroglycerin	Labetalol
Acute pulmonary edema	SBP <140 immediately	Nitroglycerin + loop diuretic	Nicardipine + loop diuretic
Acute aortic disease	SBP <120, HR <60 immediately	Esmolol + Nitroprusside	Labetalol, Nicardipine

Special Considerations

• Stimulant intoxication: Start with benzodiazepines before antihypertensives 1
• Pregnancy-related crisis: IV labetalol or nicardipine with magnesium 1
• Avoid sublingual nifedipine due to risk of precipitous BP decline 1
• Sodium nitroprusside: Use with caution due to toxicity concerns 4

Management of Hypertensive Urgency

1. Oral antihypertensive therapy is usually sufficient 1
2. Gradual BP reduction over 24-48 hours to prevent organ damage 5
3. Initial therapy: ACEI/ARB plus calcium channel blocker or thiazide diuretic, preferably as fixed-dose combination 1
4. Hospitalization generally not required, but close monitoring is essential 5

Monitoring and Follow-up

• Hypertensive Emergency:

  • Continuous BP monitoring during acute phase
  • Vital signs every 30 minutes during first 2 hours 1
  • Monitor for improvement in organ damage (renal function, proteinuria, left ventricular mass) 1

• Hypertensive Urgency:

  • Follow-up within 24 hours 1
  • Monthly follow-up until target BP reached 1
  • Target BP generally <140/90 mmHg (or <130/80 mmHg for special populations) 1

Common Pitfalls to Avoid

• Excessive BP reduction: Too rapid or excessive lowering can lead to organ hypoperfusion, especially cerebral ischemia
• Inadequate monitoring: Patients with hypertensive urgency may progress to emergency if not properly followed
• Inappropriate medication choice: Using short-acting nifedipine or hydralazine can cause unpredictable BP drops 4
• Overlooking secondary causes: Failure to identify underlying causes (pheochromocytoma, renal artery stenosis, etc.)
• Changing infusion sites: For peripheral IV nicardipine, change infusion site every 12 hours to prevent complications 2

Drug Administration Pearls

• Nicardipine: Dilute to 0.1 mg/mL; compatible with most IV fluids except sodium bicarbonate and lactated Ringer's; protect from light 2
• Clevidipine: Available as 0.5 mg/mL emulsion; photosensitive; use within 12 hours after stopper puncture 3
• IV medications: Should be administered in settings with continuous BP monitoring capabilities 1, 6