What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

For hypertensive urgency, oral antihypertensive medications are recommended with gradual blood pressure reduction over 24-48 hours, avoiding rapid decreases that could cause organ hypoperfusion. 1

Definition and Distinction

• Hypertensive urgency: Severe hypertension (typically with diastolic BP >120 mmHg) without evidence of acute target organ damage
• Hypertensive emergency: Severe hypertension with evidence of acute target organ damage (requires more aggressive treatment with IV medications)

Recommended Oral Medications for Hypertensive Urgency

First-Line Options

1. Calcium Channel Blockers

   • Nifedipine: Rapid onset (30-60 minutes)
   • Nicardipine: More gradual effect with fewer side effects

2. ACE Inhibitors/ARBs

   • Captopril: Rapid onset (30-60 minutes)
   • Short-acting formulations preferred initially

3. Beta-Blockers

   • Labetalol: Combined alpha and beta blockade
   • Metoprolol: Short-acting formulation recommended

4. Centrally Acting Agents

   • Clonidine: Effective within 2-4 hours

Treatment Algorithm

1. Initial Assessment

   • Confirm absence of target organ damage (no retinopathy with exudates/hemorrhages, no encephalopathy, no acute heart failure, no acute kidney injury)
   • Rule out secondary causes (pheochromocytoma, drug-induced, etc.)

2. Treatment Goal

   • Aim for gradual BP reduction of 20-25% over 24-48 hours 1
   • Avoid rapid decreases that could lead to organ hypoperfusion

3. Medication Selection Based on Comorbidities

   • Heart failure: ACE inhibitors/ARBs preferred
   • Coronary artery disease: Beta-blockers or calcium channel blockers
   • Diabetes/CKD: ACE inhibitors/ARBs preferred
   • Pregnancy: Labetalol or methyldopa (avoid ACE inhibitors/ARBs)
   • Cocaine/stimulant use: Avoid beta-blockers; use calcium channel blockers

4. Recommended Dual Combinations 1

   • Thiazide diuretic + ACE inhibitor/ARB
   • Calcium channel blocker + ACE inhibitor/ARB
   • Calcium channel blocker + thiazide diuretic

Important Considerations and Pitfalls

• Avoid sublingual nifedipine: Can cause unpredictable and excessive BP drops
• Caution with beta-blockers: Avoid in patients with bradycardia, heart block, bronchospasm, or suspected cocaine/methamphetamine use 1
• Monitor for rebound hypertension: Some patients (30%) who initially respond to nifedipine may experience a return to pretreatment BP levels within 3 hours 2
• Avoid excessive BP reduction: Can lead to organ hypoperfusion and worsen outcomes 1
• Screen for secondary causes: All patients with hypertensive urgency should be evaluated for underlying causes 1

Follow-up

• Schedule follow-up within 1-2 weeks 1
• For patients with suboptimally treated hypertension or suspected non-adherence, monthly visits in a specialized setting until target BP is reached
• Implement lifestyle modifications (weight management, physical activity, smoking cessation, moderate alcohol consumption)
• Adjust oral antihypertensive regimen as needed for long-term control

Special Populations

• Black patients: Initial treatment should include a diuretic or calcium channel blocker, either in combination or with a RAS blocker 3
• Black patients from Sub-Saharan Africa: Consider combination therapy including a calcium channel blocker with either a thiazide diuretic or a RAS blocker 3

Remember that while hypertensive urgency requires prompt treatment, there is no evidence that rapid BP reduction improves outcomes in these patients 4. The focus should be on safe, controlled reduction to avoid complications from excessive BP lowering.