What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

For hypertensive urgency (severe blood pressure elevation without acute end-organ damage), the recommended management is oral antihypertensive therapy with the goal of reducing blood pressure by no more than 25% within the first hour, then to 160/100 mmHg over the next 2-6 hours, and finally to normal values over the next 24-48 hours. 1

Definition and Distinction

Hypertensive urgency is defined as:

• Severe blood pressure elevation (typically >180/120 mmHg)
• Without evidence of acute end-organ damage
• Requires blood pressure reduction within 24-48 hours
• Can usually be managed in an outpatient setting 2, 1

This differs from hypertensive emergency, which involves acute end-organ damage and requires immediate BP reduction with IV medications in an intensive care setting.

Assessment and Evaluation

Before initiating treatment, evaluate for:

• Potential causes of acute BP elevation (pain, anxiety, medication non-adherence)
• Presence of symptoms suggesting target organ damage
• Medication history and potential drug interactions
• Secondary causes of hypertension 2, 1

Treatment Algorithm

Step 1: Confirm Hypertensive Urgency

• Verify BP measurements
• Rule out hypertensive emergency by assessing for signs of acute end-organ damage
• Allow patient to rest in a quiet room for 30 minutes and recheck BP 1

Step 2: Initiate Oral Antihypertensive Therapy

First-line options (based on most recent guidelines):

• ACE inhibitors (preferred based on evidence):

  • Captopril: 25 mg orally (shorter-acting formulation)
  • Use low initial doses as patients may be very sensitive to these agents 2, 3

• Alternative options:

  • ARBs: Low initial doses
  • Beta-blockers: Metoprolol (shorter-acting formulation)
  • Calcium channel blockers: Oral formulations 2, 1

Step 3: Blood Pressure Reduction Goals

• Reduce BP by no more than 25% within the first hour
• Then aim for BP <160/100 mmHg over the next 2-6 hours
• Gradually normalize BP over 24-48 hours 1

Step 4: Follow-up

• Monitor for at least several hours to ensure stability
• Check vital signs every 30 minutes during the first 2 hours
• Schedule follow-up within 24 hours
• Continue with monthly follow-up visits until target BP is reached 1

Medication Selection Considerations

When selecting an oral agent, consider:

1. Patient comorbidities:

   • For patients with coronary artery disease: Beta-blockers or calcium channel blockers
   • For patients with heart failure: ACE inhibitors or ARBs
   • For patients with renal impairment: Careful dosing of all agents 2, 1

2. Contraindications:

   • Beta-blockers: Avoid in reactive airway disease, heart block, or bradycardia
   • ACE inhibitors: Avoid in pregnancy and bilateral renal artery stenosis 2

Important Cautions

• Avoid rapid, excessive BP reduction as this can lead to complications including cerebral hypoperfusion, acute kidney injury, and worsening of neurological status 2
• Do not use sublingual nifedipine due to risk of unpredictable BP drops and adverse outcomes 4
• Avoid IV antihypertensive agents in hypertensive urgency unless oral therapy fails 1
• Be cautious with beta-blockers in patients with suspected catecholamine excess (pheochromocytoma, cocaine toxicity) 2

Prognosis and Long-term Management

Untreated hypertensive crises have poor outcomes, with mortality rates >79% at one year 1. After initial management of hypertensive urgency:

• Adjust long-term antihypertensive regimen
• Address medication adherence issues
• Screen for secondary causes of hypertension
• Monitor for regression of hypertension-mediated organ damage 1

By following this structured approach to hypertensive urgency management, you can effectively reduce blood pressure while minimizing the risk of adverse events associated with overly aggressive treatment.