What are the guidelines for managing hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency is defined as severely elevated blood pressure (typically >180/120 mmHg) without evidence of acute end-organ damage and should be treated with oral antihypertensive medications with gradual blood pressure reduction over 24-48 hours. 1

Definition and Diagnosis

• Hypertensive urgency is characterized by severe blood pressure elevation (>180/120 mmHg) without clinical evidence of acute organ damage 1
• It is critical to distinguish hypertensive urgency from hypertensive emergency, which involves target organ damage and requires immediate intervention 2, 3
• Proper diagnosis requires repeated blood pressure measurements to confirm the elevation, with measurements taken in both arms 1

Clinical Assessment

• A thorough evaluation should be performed to rule out target organ damage, including:
  • Physical examination 1
  • Fundoscopic examination to assess for retinopathy 1, 3
  • Basic laboratory tests including renal function panel 1
  • Electrocardiogram to assess for cardiac involvement 1
• Additional testing (echocardiogram, neuroimaging, chest CT) should be performed if indicated by symptoms 1

Treatment Approach

• Most guidelines recommend outpatient treatment using oral antihypertensive medications with follow-up within one week 1
• The goal is gradual blood pressure reduction over 24-48 hours, avoiding aggressive BP lowering which can lead to complications 4, 5
• Oral medications are preferred over intravenous agents for hypertensive urgency 1
• Hospital admission is generally not required for hypertensive urgency unless there are concerning features or poor follow-up 1

Medication Selection

• Oral antihypertensive agents should be selected based on the patient's comorbidities and baseline medications 2, 3
• Common effective options include:
  • ACE inhibitors (like lisinopril) 6
  • Calcium channel blockers 7, 5
  • Beta-blockers 8, 7
  • Clonidine 7, 9
• Short-acting oral formulations may be preferred initially to allow for careful titration 1

Follow-up and Long-term Management

• Close follow-up within one week is essential to ensure adequate blood pressure control 1
• Patients should be screened for secondary causes of hypertension 1, 2
• Long-term management should focus on improving medication adherence and addressing modifiable risk factors 1
• Patients with a history of hypertensive urgency remain at increased risk for cardiovascular and renal disease 1

Important Clinical Considerations

• Rapid and excessive blood pressure lowering should be avoided as it can lead to organ hypoperfusion 1, 4
• Patients with autonomic hyperreactivity due to substances like cocaine or amphetamines require special consideration, with benzodiazepines as first-line treatment 1
• Beta-blockers should be avoided in patients with cocaine-induced hypertension as they may worsen coronary vasoconstriction 1
• Patients with hypertensive urgency should be educated about the importance of medication adherence to prevent recurrence 1

Differentiation from Hypertensive Emergency

• Unlike hypertensive urgency, hypertensive emergency requires immediate hospitalization, continuous monitoring, and intravenous antihypertensive therapy 2, 3
• Hypertensive emergency is characterized by target organ damage affecting the heart, brain, kidneys, eyes, or large blood vessels 2, 3
• The mortality rate for patients with hypertensive emergency (4.6%) is significantly higher than for those with hypertensive urgency (0.8%) 1