Treatment for Hypertensive Urgency
For hypertensive urgency, oral medication according to standard drug treatment algorithms is recommended, with careful outpatient follow-up rather than hospital admission. 1
Definition and Distinction
- Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) in otherwise stable patients without acute or impending target organ damage or dysfunction 2
- Distinguished from hypertensive emergency by the absence of acute microangiopathy, which typically presents with retinopathy (flame hemorrhages, cotton wool spots, papilledema), encephalopathy, acute heart failure, or acute renal deterioration 1
Initial Management Approach
- Patients require BP reduction but do not usually need hospital admission; outpatient management with oral medication is preferred 1
- Reduce systolic blood pressure by no more than 25% within the first hour, then cautiously reduce to normal during the following 24-48 hours 2
- Goal is to reduce blood pressure to 160/100 mmHg within 2-6 hours 2
Medication Selection
- Oral therapy with ACE inhibitors, ARBs, or beta-blockers (shorter-acting formulations like captopril or metoprolol) can be effective 1
- Use low initial doses as these patients can be very sensitive to these agents 1
- Short-acting nifedipine should NOT be used due to risk of rapid, uncontrolled blood pressure falls 2
- For black patients, initial treatment should include a diuretic or a calcium channel blocker, either alone or with a RAS blocker 1
Monitoring and Follow-up
- Observe the patient for at least 2 hours to evaluate BP lowering efficacy and safety after initiating or adjusting medication 2
- Arrange appropriate follow-up to ensure continued blood pressure control 2
- More urgent outpatient review may be required to ensure BP is controlled 1
Special Considerations
- Avoid excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia 2
- Address medication compliance issues, which are often the underlying cause of hypertensive urgency 2
- Acute and severe increases in BP can be precipitated by sympathomimetics such as methamphetamine or cocaine, when caution around beta-blocker use is needed 1
- Many patients with acute pain or distress may have acutely elevated BP that will normalize when pain and distress are relieved, rather than requiring specific intervention 1
Pitfalls to Avoid
- Aggressive BP lowering should be avoided as it can lead to complications 3
- Rapid and uncontrolled or excessive BP lowering is not recommended as it can lead to further complications 1
- Do not use short-acting nifedipine due to unpredictable hypotensive effects 2
- Avoid intravenous medications which are reserved for true hypertensive emergencies 1