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

Treatment Approach for Hypertensive Urgency vs. Hypertensive Emergency

Hypertensive emergencies require immediate hospitalization and parenteral therapy, while hypertensive urgencies can be managed with oral medications and close outpatient follow-up. 1

Definitions and Differentiation

• Hypertensive Emergency: Severe BP elevation (>180/120 mmHg) with evidence of new or worsening target organ damage requiring immediate BP reduction 1

  • Examples: hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke, acute MI, acute LV failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, eclampsia 1
  • 1-year mortality rate >79% if left untreated 1

• Hypertensive Urgency: Severe BP elevation without acute or impending target organ damage 1

  • Often presents in patients who are noncompliant with or inadequately treated with antihypertensive therapy 1
  • Can be managed without hospitalization in most cases 1

Management of Hypertensive Emergency

Initial Approach

• Admission to ICU is recommended for continuous BP monitoring and parenteral administration of appropriate agents 1
• Monitoring: Continuous arterial BP monitoring is recommended to prevent "overshoot" (excessive BP reduction) 1

BP Reduction Targets

• For compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma crisis):

  • Reduce SBP to <140 mmHg during first hour 1
  • For aortic dissection, further reduce to <120 mmHg 1

• For non-compelling conditions:

  • Reduce BP by no more than 25% within first hour 1
  • Then, if stable, to 160/100 mmHg within next 2-6 hours 1
  • Then cautiously to normal during following 24-48 hours 1

Medication Selection for Hypertensive Emergency

Medication choice depends on the specific type of target organ damage:

1. First-line agents for most hypertensive emergencies:

   • Labetalol: IV bolus 20-80 mg every 10 min or 0.4-1.0 mg/kg/h IV infusion 1
   • Nicardipine: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1, 2

2. Specific conditions:

   • Acute pulmonary edema: Clevidipine, nitroglycerin, or nitroprusside (with loop diuretic) 1
   • Acute coronary syndromes: Nitroglycerin (first-line), esmolol, labetalol, or nicardipine 1
   • Acute aortic dissection: Esmolol plus nitroprusside/nitroglycerin (target SBP <120 mmHg and heart rate <60 bpm) 1
   • Acute renal failure: Clevidipine, fenoldopam, or nicardipine 1
   • Eclampsia/preeclampsia: Hydralazine, labetalol, or nicardipine (avoid ACE inhibitors, ARBs, renin inhibitors, and nitroprusside) 1

Management of Hypertensive Urgency

• Reinstitute or intensify oral antihypertensive therapy 1
• Avoid rapid BP reduction as this can lead to cardiovascular complications 1
• Oral medications that can be used include:
  • Captopril, labetalol, or nifedipine retard (extended-release) 1, 3
  • Avoid short-acting nifedipine as it can cause precipitous BP drops 1
• Observation period of at least 2 hours is suggested to evaluate BP lowering efficacy and safety 1
• Arrange follow-up within 24-48 hours to ensure adequate BP control 1

Important Considerations and Pitfalls

• Avoid excessive BP reduction: Rapid, excessive falls in BP can precipitate renal, cerebral, or coronary ischemia 1

• Consider chronic hypertension: Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals 1

• Special populations:

  • Ischemic stroke: Limited evidence for immediate antihypertensive treatment; generally, BP-lowering medication is withheld unless BP >220/120 mmHg 1
  • Substance-induced hypertension (cocaine, amphetamines): Begin with benzodiazepines before adding antihypertensive therapy 1
  • Pheochromocytoma: Avoid labetalol (may worsen hypertension); use phentolamine, nitroprusside, urapidil, or nicardipine 1

• Follow-up after hypertensive emergency: Patients remain at increased risk of cardiovascular and renal disease compared to hypertensive patients without a history of emergency 1

  • Key prognostic factors: elevated cardiac troponin-I levels and renal impairment at presentation 1
  • BP control and proteinuria management during follow-up are crucial for renal survival 1