What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), initiate oral antihypertensive medications with gradual BP reduction over 24-48 hours in the outpatient setting, avoiding rapid or excessive BP lowering that could precipitate organ ischemia. 1, 2

Distinguishing Urgency from Emergency

The critical first step is confirming the absence of acute target organ damage, which differentiates urgency from emergency:

• Assess for target organ damage including hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, and eclampsia 3, 2
• Perform fundoscopic examination to evaluate for acute retinopathy, which indicates hypertensive emergency rather than urgency 4
• Obtain basic laboratory tests including renal function panel and electrocardiogram to rule out acute kidney injury or cardiac ischemia 4
• If target organ damage is present, this is a hypertensive emergency requiring ICU admission and IV medications 3, 2

Blood Pressure Reduction Goals

The approach to BP lowering in hypertensive urgency differs fundamentally from emergency management:

• Reduce BP gradually over 24-48 hours rather than immediately 1, 2
• Target BP reduction to 160/100 mmHg within 2-6 hours, then cautiously to normal over 24-48 hours 1
• Avoid reducing SBP by more than 25% in the first hour, as excessive reduction can precipitate renal, cerebral, or coronary ischemia 1, 2

Medication Selection

Use oral antihypertensive agents rather than IV medications, which are reserved exclusively for hypertensive emergencies 1, 2:

• ACE inhibitors, ARBs, or beta-blockers are recommended first-line oral agents, using low initial doses due to potential sensitivity 1, 2
• For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or combined with a RAS blocker 1
• Extended-release calcium channel blockers may be used, but short-acting nifedipine should be avoided due to risk of rapid, uncontrolled BP falls 1

Special Populations and Pitfalls

• For patients with cocaine or methamphetamine-induced hypertension, benzodiazepines are first-line treatment; avoid beta-blockers as they may worsen coronary vasoconstriction 2, 4
• Many patients with acute pain or distress will have transiently elevated BP that normalizes when pain is relieved, rather than requiring specific antihypertensive intervention 1
• Address medication non-compliance, which is often the underlying cause of hypertensive urgency 1, 4

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

Arrange close follow-up within one week to ensure adequate BP control and prevent recurrence 4:

• Screen for secondary causes of hypertension 4
• Focus on improving medication adherence and addressing modifiable risk factors 4
• Educate patients that those with history of hypertensive urgency remain at increased risk for cardiovascular and renal disease 4

What NOT to Do

• Do not admit to hospital unless there are concerning features or poor follow-up capability; outpatient management is appropriate 1, 4
• Do not use IV antihypertensive agents, which are reserved for true hypertensive emergencies 1, 2
• Do not rapidly lower BP, as this can lead to organ hypoperfusion and ischemic complications 1, 4
• Do not use short-acting nifedipine due to unpredictable and potentially dangerous rapid BP reduction 1