What is the initial management for full inpatient treatment 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.

Initial Assessment and Diagnosis

• Confirm elevated blood pressure with multiple measurements
• Distinguish from hypertensive emergency by assessing for target organ damage:
  • Neurological: altered mental status, seizures, focal deficits
  • Cardiovascular: chest pain, acute heart failure, aortic dissection
  • Renal: acute kidney injury, hematuria
  • Ophthalmologic: papilledema, retinal hemorrhages

Pharmacological Management

First-Line Treatment Options

1. Oral Antihypertensive Medications:

   • Begin with low doses and titrate as needed
   • Goal: Reduce blood pressure gradually over 24-48 hours
   • Avoid rapid decreases which may precipitate ischemic events

2. Preferred Agents:

   • Beta-blockers: Labetalol (combined alpha and beta blocker)
     • Dosing: Start with 200-400 mg orally, can repeat every 2-3 hours
     • Advantages: Predictable response, minimal reflex tachycardia 2
   • Calcium channel blockers:
     • Avoid short-acting nifedipine due to risk of precipitous BP drops 1
     • Longer-acting dihydropyridines may be added if beta-blockers alone are insufficient 3
   • ACE inhibitors or ARBs:
     • Add if patient has anterior MI, LV dysfunction, heart failure, or diabetes 3

Monitoring and Titration

• Monitor BP every 15-30 minutes initially, then hourly once stabilized
• Target BP: <130/80 mmHg, but avoid reducing diastolic BP below 60 mmHg, especially in older patients with wide pulse pressures 3
• For gradual reduction, adjust medication doses every 2-3 hours based on response

Special Clinical Scenarios

Acute Coronary Syndrome with Hypertension

• First-line: IV nitroglycerin, furosemide, and short-acting or IV ACE inhibitor 3
• If tachycardia or ischemia predominates: IV esmolol with IV nitroglycerin 3
• Monitor closely for hypotension, especially with ongoing ischemia

Flash Pulmonary Edema with Hypertension

• IV nitroglycerin, furosemide, and short-acting or IV ACE inhibitor 3
• Aggressive but careful BP lowering with close monitoring

Elderly Patients

• Start with lower doses due to increased sensitivity to medications 1
• Be cautious with wide pulse pressures to avoid lowering diastolic BP below 60 mmHg 3

Transition to Oral Therapy and Discharge Planning

• If transferring to oral antihypertensive agents other than nicardipine capsules, initiate oral therapy upon discontinuation of IV medication 4
• When switching to TID regimen of nicardipine capsules, administer first dose 1 hour prior to discontinuation of infusion 4
• Ensure follow-up within 7 days after discharge 3, 1
• Provide patient education on medication adherence and lifestyle modifications

Common Pitfalls to Avoid

1. Overly aggressive BP reduction: Can lead to organ hypoperfusion, especially in patients with chronic hypertension who have shifted autoregulation curves

2. Inappropriate medication selection:

   • Avoid sodium nitroprusside for prolonged use due to cyanide toxicity risk 3, 5
   • Avoid immediate-release nifedipine due to risk of precipitous BP drops 1, 5
   • Avoid hydralazine due to unpredictable antihypertensive effects 5

3. Inadequate monitoring: Patients require close observation during initial treatment phase

4. Failure to identify and treat underlying causes: Address pain, anxiety, medication non-adherence, or secondary causes of hypertension

5. Contraindications to specific medications 3:

   • Beta-blockers: Avoid in asthma, high-grade AV block
   • Calcium channel blockers (verapamil/diltiazem): Avoid in heart failure, high-grade AV block
   • ACE inhibitors/ARBs: Avoid in pregnancy, bilateral renal artery stenosis, hyperkalemia

By following this structured approach to hypertensive urgency management, clinicians can effectively reduce blood pressure while minimizing the risk of adverse events and preventing progression to hypertensive emergency.