What is the management of hypertensive urgency in the Emergency Room (ER)?

From the Guidelines

Hypertensive urgency in the ER requires prompt but controlled blood pressure reduction over 24-48 hours, not immediate normalization, as recommended by the most recent guidelines 1. The management of hypertensive urgency in the Emergency Room (ER) involves a careful approach to reduce blood pressure while avoiding complications.

Key Considerations

• Assessing for end-organ damage through physical examination, ECG, urinalysis, and basic labs to rule out hypertensive emergency 1
• Identifying and addressing precipitating factors such as medication non-adherence, pain, or anxiety 1
• Determining the type of BP-lowering treatment required based on the affected target organ(s) and any precipitating cause for the acute rise in BP 1

Treatment Approach

• Begin with oral medications like labetalol 200-400mg, amlodipine 5-10mg, or captopril 25mg, as these are effective and can be titrated to achieve the desired blood pressure reduction 1
• Monitor blood pressure every 30-60 minutes initially, aiming for a 20-25% reduction in the first few hours, to avoid rapid decreases that can cause organ hypoperfusion 1
• Once stabilized, transition to an appropriate outpatient regimen, typically including a combination of antihypertensives like an ACE inhibitor or ARB plus a calcium channel blocker or thiazide diuretic 1

Follow-up and Education

• Ensure close follow-up within 1-2 weeks to monitor blood pressure and adjust treatment as needed 1
• Patient education about medication adherence, lifestyle modifications, and warning signs for return is essential to prevent future episodes of hypertensive urgency 1

From the FDA Drug Label

In a clinical pharmacologic study in severe hypertensives, an initial 0. 25 mg/kg injection of labetalol HCl, administered to patients in the supine position, decreased blood pressure by an average of 11/7 mmHg. Additional injections of 0.5 mg/kg at 15-minute intervals up to a total cumulative dose of 1.75 mg/kg of labetalol HCl caused further dose-related decreases in blood pressure. Some patients required cumulative doses of up to 3. 25 mg/kg. Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg

The management of hypertensive urgency in the Emergency Room (ER) with labetalol (IV) may involve:

• An initial dose of 0.25 mg/kg administered to patients in the supine position
• Additional doses of 0.5 mg/kg at 15-minute intervals as needed, up to a total cumulative dose of 1.75 mg/kg or more
• Alternatively, a continuous intravenous infusion with a mean dose of 136 mg over a period of 2 to 3 hours 2

From the Research

Management of Hypertensive Urgency in the Emergency Room (ER)

• Hypertensive urgency is defined as a severe elevation in blood pressure without end-organ damage, and its management differs from that of hypertensive emergency 3, 4, 5, 6, 7.
• The primary goal of intervention in hypertensive urgency is to safely reduce blood pressure, usually with oral antihypertensive agents 3, 4, 5.
• Patients with hypertensive urgency can usually be managed with oral agents, such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 6.
• Blood pressure should be lowered gradually over 24 to 48 hours using oral antihypertensives 4.
• The choice of oral antihypertensive agent should be guided by the underlying pathophysiological and clinical findings, mechanism of action, and potential for adverse effects 4.

Oral Antihypertensive Agents for Hypertensive Urgency

• Captopril should be avoided in patients with bilateral renal artery stenosis or unilateral renal artery stenosis in patients with a solitary kidney 4.
• Nifedipine and other dihydrophyridines increase heart rate, whereas clonidine, beta-blockers, and labetalol tend to decrease it 4.
• Labetalol and beta-blockers are contraindicated in patients with bronchospasm and bradycardia or heart blocks 4.
• Clonidine should be avoided if mental acuity is desired 4.

Comparison with Hypertensive Emergency

• Hypertensive emergency requires immediate reduction in blood pressure to avoid further end-organ damage, usually with intravenous antihypertensive agents 3, 4, 5, 6, 7.
• Patients with hypertensive emergencies are best treated in an intensive care unit with titratable intravenous hypotensive agents 3, 5.
• Rapid-acting intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside, are available for the management of hypertensive emergencies 3, 5.