What is the treatment approach for hypertensive urgency vs emergency vs accelerated hypertension?

Treatment Approach for Hypertensive Urgency vs Emergency vs Accelerated Hypertension

The treatment of hypertensive crisis must be tailored based on classification as either hypertensive emergency (requiring immediate IV therapy for end-organ damage) or hypertensive urgency (requiring oral therapy within 24-48 hours without end-organ damage). 1, 2

Definitions and Classification

• Hypertensive Emergency: Severe hypertension (typically >180/120 mmHg) WITH evidence of acute target organ damage
• Hypertensive Urgency: Severe hypertension (typically >180/120 mmHg) WITHOUT evidence of acute target organ damage
• Accelerated Hypertension: A severe form of hypertension characterized by rapid progression, often with retinal hemorrhages and exudates but without papilledema (which would indicate malignant hypertension)

Assessment for End-Organ Damage

Evaluate for:

• Neurological: Encephalopathy, stroke, intracranial hemorrhage
• Cardiovascular: Acute coronary syndrome, acute heart failure, aortic dissection
• Renal: Acute kidney injury, proteinuria
• Ophthalmologic: Retinal hemorrhages, exudates, papilledema

Treatment of Hypertensive Emergency

General Approach:

• Immediate BP reduction using IV medications
• Target: Reduce mean arterial pressure by 20-25% within the first hour 2
• Continuous BP monitoring (preferably intra-arterial)
• ICU admission recommended

First-Line IV Medications:

1. Nicardipine:

   • Initial dose: 5 mg/h IV
   • Titration: Increase by 2.5 mg/h every 5-15 minutes
   • Maximum dose: 15 mg/h 2, 3
   • Advantages: Predictable response, minimal effect on heart rate

2. Clevidipine:

   • Initial dose: 1-2 mg/h IV
   • Titration: Double dose every 90 seconds initially, then adjust more gradually
   • Advantages: Ultra-short acting, rapid onset/offset

3. Labetalol:

   • Dosing: 0.3-1.0 mg/kg IV (maximum 20 mg)
   • Repeat every 10 minutes or use 0.4-1.0 mg/kg/h IV infusion
   • Contraindicated in: 2nd/3rd degree heart block, severe bradycardia, asthma, decompensated heart failure 2

4. Sodium Nitroprusside:

   • Dosing: 0.3-0.5 mcg/kg/min IV
   • Titration: Increase in increments of 0.5 mcg/kg/min
   • Caution: Risk of cyanide toxicity with prolonged use

Condition-Specific BP Targets:

• Aortic dissection: <120 mmHg systolic within the first hour 2
• Severe preeclampsia/eclampsia: <140 mmHg systolic within the first hour 2
• Hypertensive encephalopathy: Reduce mean arterial pressure by 20-25% immediately 2
• Acute ischemic stroke: Only treat if BP >220/120 mmHg, reduce by 15% within the first hour 2
• Acute hemorrhagic stroke: Target 130-180 mmHg systolic immediately 2
• Acute coronary event: <140 mmHg systolic immediately 2

Special Situations:

• Drug-induced hypertension (amphetamines/cocaine): Begin with benzodiazepines first; if additional BP lowering needed, use phentolamine, nicardipine, or nitroprusside 1
• Pheochromocytoma crisis: Phentolamine, nitroprusside, or urapidil; avoid labetalol (may worsen hypertension) 1
• Cytotoxic/anti-angiogenic drug-induced hypertension: Withhold offending agent until BP controlled with oral medication 1

Treatment of Hypertensive Urgency

General Approach:

• Oral medications to reduce BP gradually over 24-48 hours 4, 5
• Hospitalization generally not required
• Ensure follow-up care

Recommended Medications:

• Labetalol: 200-400 mg orally, onset 1-2 hours 2
• Nifedipine (not immediate-release)
• Captopril
• Clonidine

Transitioning from IV to Oral Therapy

• Begin oral antihypertensives 1 hour before discontinuing IV medications to prevent rebound hypertension 2
• When switching to oral nicardipine, administer first dose 1 hour prior to discontinuation of IV infusion 3

Follow-Up Care

• Schedule follow-up within 1-2 weeks 2
• For patients with suboptimal treatment or suspected non-adherence, monthly visits until target BP is reached 1, 2
• Address risk factors and implement lifestyle modifications
• Patients with history of hypertensive emergency remain at increased risk for cardiovascular and renal disease (4.6% mortality vs 0.8% in those without hypertensive emergency) 1

Common Pitfalls to Avoid

1. Excessive BP reduction: Too rapid or excessive lowering can lead to organ hypoperfusion, especially in stroke
2. Neglecting transition to oral therapy: Plan for transition to prevent rebound hypertension
3. Failing to identify secondary causes: Evaluate for underlying causes like pheochromocytoma, renal artery stenosis
4. Using contraindicated medications: Avoid beta-blockers in cocaine-induced hypertension; use caution with ACE inhibitors in volume-depleted patients
5. Missing medication non-adherence: Often a key factor in hypertensive crises