What is the initial treatment for a patient with hypertensive urgency?

Treatment for Hypertensive Urgency

For hypertensive urgency, the initial treatment should be oral antihypertensive medication according to standard drug treatment algorithms with careful outpatient follow-up rather than hospital admission. 1

Definition and Assessment

• Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) without acute target organ damage or dysfunction 2
• Distinguished from hypertensive emergency by the absence of acute microangiopathy, which typically presents with retinopathy, encephalopathy, acute heart failure, or acute renal deterioration 2
• Common symptoms include severe headache, shortness of breath, epistaxis, or severe anxiety 2

Initial Management Approach

• Oral medication is the preferred approach for hypertensive urgency, with careful outpatient follow-up 1
• The goal is to reduce blood pressure by no more than 25% within the first hour, then cautiously reduce to normal during the following 24-48 hours 2
• Target blood pressure reduction should aim for 160/100 mmHg within 2-6 hours 2
• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate efficacy and safety 2

Medication Selection

For Non-Black Patients:

1. Start with low dose ACE inhibitor or ARB 1
2. If needed, add a dihydropyridine calcium channel blocker (DHP-CCB) 1
3. Increase to full dose if necessary 1
4. Add thiazide/thiazide-like diuretic if needed 1

For Black Patients:

1. Start with low dose ARB plus DHP-CCB or DHP-CCB plus thiazide/thiazide-like diuretic 1
2. Increase to full dose if necessary 1
3. Add diuretic or ACE inhibitor/ARB if not already included 1

Important Considerations and Precautions

• Avoid rapid and uncontrolled or excessive blood pressure lowering as it can lead to further complications including cerebral, renal, or coronary ischemia 1, 2
• Short-acting nifedipine should NOT be used due to risk of rapid, uncontrolled blood pressure falls 2
• Use low initial doses of ACE inhibitors, ARBs, or beta-blockers as patients may be very sensitive to these agents 1, 2
• Exercise caution with beta-blocker use in patients with acute BP increases precipitated by sympathomimetics such as methamphetamine or cocaine 1, 2
• Many patients with acute pain or distress may have elevated BP that will normalize when pain and distress are relieved, rather than requiring specific intervention 1

Follow-up and Monitoring

• Arrange appropriate follow-up to ensure continued blood pressure control 2
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 2
• Target BP should be <130/80 mmHg for long-term management 1
• In elderly patients with wide pulse pressures, monitor carefully when lowering systolic BP to avoid diastolic BP falling below 60 mmHg, which may worsen myocardial ischemia 1

Special Situations

• For patients with concomitant coronary syndromes, short-acting beta-selective blockers without intrinsic sympathomimetic activity are recommended, in addition to nitrates for symptom control 1
• If beta-blockers are contraindicated, a non-dihydropyridine CCB (verapamil or diltiazem) may be substituted, but not if there is LV dysfunction 1
• For patients with hypertensive urgency and acute pain, addressing the pain may help normalize blood pressure without specific antihypertensive intervention 1