What is the protocol for managing hypertensive urgency, specifically the initial medication and dosing?

Management of Hypertensive Urgency

For hypertensive urgency (BP >180/120 mmHg without evidence of target organ damage), the recommended approach is to reduce blood pressure by no more than 25% within the first hour, followed by gradual reduction to 160/100 mmHg over the next 2-6 hours using oral antihypertensive medications. 1, 2

Definition and Initial Assessment

• Hypertensive urgency is defined as severe blood pressure elevation (>180/120 mmHg) without evidence of new or progressive target organ damage 1, 2
• This differs from hypertensive emergency, which involves acute organ damage and requires immediate intervention with intravenous medications 1, 2
• Proper blood pressure measurement technique should be used to confirm the reading and exclude pseudoresistance 2

First-Line Medication Options for Hypertensive Urgency

• Oral medications are preferred for hypertensive urgency, with recommended first-line options including:
  • Captopril (ACE inhibitor) 1, 2
  • Labetalol (combined alpha and beta-blocker) 1, 2
  • Extended-release nifedipine (calcium channel blocker) 1

Dosing and Administration Guidelines

• For labetalol, which is a commonly used agent due to its combined alpha and beta-blocking properties:
  • Initial oral dose should be carefully titrated 3
  • The medication has an onset of action of 5-10 minutes and a duration of 3-6 hours 1
  • Contraindicated in patients with 2nd or 3rd degree AV block, systolic heart failure, asthma, and bradycardia 1

Blood Pressure Reduction Goals

• Reduce blood pressure by no more than 25% within the first hour 1, 2, 4
• Further reduce to 160/100 mmHg within the next 2-6 hours if stable 1, 2, 4
• Avoid rapid blood pressure reduction, which can lead to cerebral, cardiac, or renal hypoperfusion 2, 4

Monitoring and Observation

• An observation period of at least 2 hours is recommended to evaluate blood pressure lowering efficacy and safety 1
• If signs of acute end-organ damage develop during observation, or if blood pressure remains severely elevated despite oral therapy, admission to intensive care and IV antihypertensive therapy become necessary 1, 2

Special Considerations

• In patients with autonomic hyperreactivity (e.g., cocaine intoxication), benzodiazepines should be initiated first 1, 2
• For patients with coronary ischemia, nitroglycerin may be appropriate 1, 5
• Identify and discontinue contributing substances, including NSAIDs, sympathomimetics, stimulants, oral contraceptives, and licorice 2
• Address medication adherence issues, as many hypertensive urgencies result from non-compliance 1, 2

When to Escalate to Intravenous Therapy

• If oral therapy fails or if the patient develops signs of target organ damage (converting to hypertensive emergency), intravenous medications should be initiated 1, 2
• First-line IV medications for hypertensive emergencies include:
  • Labetalol 1, 6, 7
  • Nicardipine 1, 6
  • Clevidipine 1, 6
  • Avoid sodium nitroprusside when possible due to toxicity concerns 1, 6, 7

Follow-up Care

• Schedule frequent follow-up visits (at least monthly) until target blood pressure is reached 1, 2
• Continue follow-up until hypertension-mediated organ damage has regressed 2
• Address lifestyle factors contributing to hypertension, such as obesity, physical inactivity, excessive alcohol, and high-salt diet 2