What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency should be managed with oral antihypertensive medications and close outpatient follow-up rather than hospital admission, with a goal of gradually reducing blood pressure over 24-48 hours. 1, 2

Definition and Diagnosis

• Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) without evidence of acute or impending target organ damage 3, 1
• Distinguish from hypertensive emergency by assessing for absence of target organ damage such as hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute LV failure, unstable angina, aortic dissection, or acute renal failure 3, 2
• Proper diagnosis requires repeated BP measurements to confirm elevation 3
• Diagnostic testing for end organ damage should include physical examination, funduscopic examination, renal panel, and electrocardiogram 3

Treatment Approach

• For hypertensive urgency, reduce systolic blood pressure by no more than 25% within the first hour 3, 4
• Target BP reduction to 160/100 mmHg within 2-6 hours, then gradually reduce to normal over 24-48 hours 3, 1
• Use oral antihypertensive medications rather than intravenous agents 3, 1
• Recommended oral medications include:
  • ACE inhibitors, ARBs, or beta-blockers (using low initial doses due to potential sensitivity) 3, 2
  • For Black patients, consider initial treatment with a diuretic or calcium channel blocker, either alone or with a RAS blocker 1

Important Precautions

• Avoid short-acting nifedipine due to risk of rapid, uncontrolled blood pressure falls 1, 5
• Avoid excessive or rapid BP reduction that may precipitate renal, cerebral, or coronary ischemia 3, 4
• Exercise caution with beta-blocker use in patients with hypertension precipitated by sympathomimetics such as methamphetamine or cocaine 3, 2
• Remember that patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals 3, 2

Monitoring and Follow-up

• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 1
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 1
• Arrange appropriate follow-up within one week to ensure continued blood pressure control 3, 1
• Many patients with acute pain or distress may have elevated BP that normalizes when pain and distress are relieved, without requiring specific intervention 3

Pitfalls to Avoid

• Do not use intravenous medications for hypertensive urgency (reserve for true hypertensive emergencies) 1, 6
• Avoid aggressive BP lowering that can lead to organ hypoperfusion 2, 7
• Do not confuse hypertensive urgency with hypertensive emergency, which requires ICU admission and parenteral medications 3, 2