What is the recommended treatment for hypertensive urgency?

Treatment for Hypertensive Urgency

For hypertensive urgency, defined as severe blood pressure elevation (>180/120 mmHg) without acute target organ damage, oral medication with careful outpatient follow-up is recommended rather than hospital admission. 1

Definition and Diagnosis

• Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) in otherwise stable patients without acute or impending change in target organ damage or dysfunction 1
• It must be distinguished from hypertensive emergency by assessing for signs of target organ damage, such as hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure, unstable angina, aortic dissection, or acute renal failure 1
• Patients with hypertensive urgency often present with symptoms like severe headache, shortness of breath, epistaxis, or severe anxiety 1

Recommended Treatment Approach

• Oral medications are the treatment of choice for hypertensive urgency 1, 2
• First-line oral medications include:
  • ACE inhibitors (e.g., captopril) 1, 2
  • ARBs 1
  • Beta-blockers (e.g., labetalol) 1, 2
  • Calcium channel blockers (extended-release formulations) 1, 2
• For black patients, initial treatment should include a diuretic or a calcium channel blocker, either alone or with a RAS blocker 1
• Low initial doses should be used due to potential sensitivity to medications 1

Blood Pressure Reduction Goals

• Reduce systolic blood pressure by no more than 25% within the first hour 1
• Target blood pressure of 160/100 mmHg within 2-6 hours 1, 3
• Cautiously reduce to normal during the following 24-48 hours 1
• Avoid excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia 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 1, 2
• Arrange appropriate follow-up to ensure continued blood pressure control 1
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 1

Important Cautions and Contraindications

• Short-acting nifedipine should NOT be used due to risk of rapid, uncontrolled blood pressure falls 1
• Intravenous medications should be avoided in hypertensive urgency and are reserved for true hypertensive emergencies 1, 3
• Use beta-blockers with caution in patients with reactive airway disease or COPD 3
• Exercise caution with beta-blocker use in patients with acute and severe increases in blood pressure precipitated by sympathomimetics such as methamphetamine or cocaine 1

Special Considerations

• Many patients with acute pain or distress may have acutely elevated blood pressure that will normalize when pain and distress are relieved, rather than requiring specific intervention 1
• Abrupt withdrawal of beta-adrenergic blocking agents in patients with coronary artery disease can exacerbate angina and, in some cases, lead to myocardial infarction and ventricular dysrhythmias 4
• Labetalol, which has both alpha and beta-blocking properties, produces dose-related falls in blood pressure without reflex tachycardia and without significant reduction in heart rate 4
• Due to the alpha1-receptor blocking activity of labetalol, blood pressure is lowered more in the standing than in the supine position, so patients should be monitored when moving to an erect position 4