What are the medications and doses for managing hypertensive urgency?

Management of Hypertensive Urgency

For hypertensive urgency, oral medications are recommended with careful outpatient follow-up rather than hospital admission, using standard antihypertensive agents according to established treatment algorithms. 1

Definition and Assessment

• 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 1
• Distinguished from hypertensive emergency by the absence of acute microangiopathy, which typically presents with retinopathy, encephalopathy, acute heart failure, or acute renal deterioration 1
• Patients often present with symptoms like severe headache, shortness of breath, epistaxis, or severe anxiety 1

Medication Selection and Dosing

First-line Oral Medications:

• ACE inhibitors:

  • Captopril: 25 mg initially, may repeat 25-50 mg at 1-2 hour intervals 1
  • Enalapril: 5-10 mg once daily, may increase to 20 mg daily 2

• ARBs:

  • Losartan: Initial dose 50 mg once daily, can be increased to maximum 100 mg once daily as needed 3
  • Lower starting dose of 25 mg recommended for patients with possible intravascular depletion (e.g., on diuretic therapy) 3

• Beta-blockers (cardioselective):

  • Metoprolol tartrate: 100-200 mg daily in divided doses 2
  • Metoprolol succinate: 50-200 mg once daily 2
  • Bisoprolol: 2.5-10 mg once daily 2

• Calcium channel blockers:

  • Extended-release nifedipine (avoid short-acting formulations) 1
  • Amlodipine: 5-10 mg once daily 2

Special Population Considerations:

• For Black patients: Initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 1

  • Hydrochlorothiazide: 12.5-50 mg once daily 4
  • Amlodipine: 5-10 mg once daily 2

• For patients with possible sympathomimetic-induced hypertension (methamphetamine or cocaine): Avoid beta-blockers due to risk of unopposed alpha-adrenergic stimulation 1, 2

Treatment Protocol

1. Initial BP Reduction Goal:

   • Reduce systolic blood pressure by no more than 25% within the first hour 1
   • Aim for BP of 160/100 mmHg within 2-6 hours 1
   • Complete normalization should occur gradually over 24-48 hours 1

2. Monitoring:

   • Observe patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 1
   • Arrange appropriate follow-up within 24-72 hours to ensure continued blood pressure control 1

3. Avoid Common Pitfalls:

   • Do NOT use short-acting nifedipine due to risk of rapid, uncontrolled blood pressure falls 1
   • Avoid rapid and excessive BP lowering which can lead to renal, cerebral, or coronary ischemia 1
   • Intravenous medications should be reserved for true hypertensive emergencies 1, 5
   • Use low initial doses of oral medications as patients with hypertensive urgency may be very sensitive to these agents 1

Special Considerations

• Many patients with acute pain or distress may have elevated BP that will normalize when pain and distress are relieved, rather than requiring specific antihypertensive intervention 1
• Address medication non-compliance issues, which are often the underlying cause of hypertensive urgency 1
• For patients with comorbid conditions, medication selection should be tailored:
  • For patients with coronary artery disease: Beta-blockers or calcium channel blockers 2
  • For patients with heart failure: ACE inhibitors or ARBs 2
  • For patients with diabetes or chronic kidney disease: ACE inhibitors or ARBs 2

Evidence Quality

• The recommendations are based on guidelines from the American College of Cardiology/American Heart Association and European Society of Cardiology 2, 1
• Evidence supports ACE inhibitors as having superior effect in treating hypertensive urgencies compared to calcium channel blockers, with fewer adverse effects such as headache and flushing 6
• Newer research continues to support oral therapy for hypertensive urgency rather than parenteral agents, which should be reserved for true hypertensive emergencies 5