From the Guidelines
Hypertensive urgency should be managed with oral antihypertensive medications to gradually lower blood pressure over 24-48 hours, without the need for immediate reduction in blood pressure or hospitalization. The goal is to reduce blood pressure by no more than 25% in the first 24 hours to avoid hypoperfusion complications, as stated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
Key Considerations
- Hypertensive urgency is defined as severe elevation in blood pressure (typically >180/120 mmHg) without evidence of acute end-organ damage, as noted in the guideline 1.
- First-line medications for hypertensive urgency include labetalol, captopril, or amlodipine, which can be administered orally to gradually lower blood pressure.
- Blood pressure should be monitored every 30-60 minutes initially, with a goal of reducing it by no more than 25% in the first 24 hours.
- Patients should be evaluated for underlying causes such as medication non-adherence, renal disease, or endocrine disorders.
Management Approach
- Oral antihypertensive medications are preferred over IV medications for hypertensive urgency, as they allow for a more gradual reduction in blood pressure.
- The gradual reduction approach is crucial because rapid decreases in blood pressure can lead to cerebral, cardiac, or renal ischemia, especially in patients whose bodies have adapted to chronically elevated pressures, as highlighted in the guideline 1.
- Patients with hypertensive urgency do not require ICU admission, but should follow up within 24-72 hours to adjust their antihypertensive regimen.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Hypertensive Urgency
- Hypertensive urgency is defined as severe hypertension without acute end-organ damage, and its management differs from that of hypertensive emergency 2, 3.
- The primary goal of intervention in hypertensive urgency is to safely reduce blood pressure, and this can usually be achieved with oral antihypertensive agents 2, 3.
- The reduction in blood pressure should be gradual, with a goal of reducing the blood pressure to baseline or normal over a period of 24-48 hours 3.
- Nifedipine, a calcium channel blocker, has been shown to be effective in the treatment of hypertensive urgencies, producing a prompt and consistent reduction in systemic arterial pressure with minimal adverse effects 4, 5.
Comparison with Hypertensive Emergency
- Hypertensive emergency, on the other hand, requires immediate reduction in blood pressure with intravenous antihypertensive medications, as it is characterized by acute end-organ damage 2, 3, 6.
- The choice of antihypertensive therapy regimen for hypertensive emergency should be based on the underlying end-organ damage, and fast-acting, easily controllable, and intravenously administered substances should be preferred 6.
- A deliberate, rapid reduction in blood pressure of no more than 20-25% of the initial value is usually sufficient for extracerebral causes, with a subsequent systolic blood pressure target of 160/100 mmHg aimed for within the next 2-6 hours 6.
Treatment Options
- Oral antihypertensive agents, such as nifedipine, can be used to treat hypertensive urgency, while intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside, are typically used to treat hypertensive emergency 4, 2, 6.
- Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages over other available agents in the management of hypertensive crises 2.
- However, sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided, and nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to their significant toxicities and/or adverse effects 2.