What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

Definition and Key Distinction

For hypertensive urgency (severe BP elevation >180/120 mmHg without acute target organ damage), treat with oral antihypertensive medications and avoid intravenous agents, which are reserved exclusively for hypertensive emergencies. 1

• Hypertensive urgency is distinguished from emergency by the absence of acute target organ damage such as hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure, unstable angina, aortic dissection, or acute renal failure 1
• Many patients with acute pain or distress may have acutely elevated BP that will normalize when the underlying pain or distress is relieved, rather than requiring specific antihypertensive intervention 1

Blood Pressure Reduction Goals

Reduce systolic blood pressure by no more than 25% within the first hour, then cautiously reduce to 160/100 mmHg within 2-6 hours, with gradual normalization over 24-48 hours. 1, 2

• Excessive or rapid BP reduction can precipitate renal, cerebral, or coronary ischemia and should be avoided 1
• The goal is controlled BP reduction without risk of hypotension 2

First-Line Oral Medications

Use oral ACE inhibitors (captopril), combined alpha/beta-blockers (labetalol), or extended-release calcium channel blockers (nifedipine ER) as first-line agents. 1, 2

Specific Medication Options:

• Captopril (ACE inhibitor): Effective first-line option with onset within 0.5-1 hour 2, 3
• Labetalol (combined alpha and beta-blocker): Maximal effect at 2-4 hours 2, 3
• Extended-release nifedipine: Effective option, but never use short-acting or sublingual nifedipine due to risk of rapid, uncontrolled BP falls 1

Special Population Considerations:

• For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or combined with a RAS blocker 1
• Use low initial doses of ACE inhibitors, ARBs, or beta-blockers due to potential sensitivity 1

Critical Pitfalls to Avoid

• Do NOT use intravenous medications for hypertensive urgency—these are reserved for true hypertensive emergencies 1
• Do NOT use short-acting or sublingual nifedipine due to unpredictable, rapid BP drops 1
• Avoid beta-blockers in patients with acute BP elevation precipitated by sympathomimetics such as methamphetamine or cocaine 1
• Do not aggressively lower BP in asymptomatic patients, as excessive reduction causes more harm than benefit 1

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, 2
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 1
• Arrange appropriate outpatient follow-up rather than hospital admission, with frequent visits (at least monthly) until target BP is reached 1, 2

Special Clinical Scenarios

• Autonomic hyperreactivity (cocaine intoxication): Initiate benzodiazepines first before antihypertensives 2
• Coronary ischemia: Use nitroglycerin and aspirin 2
• Pain-related hypertension: Treat the underlying pain or distress first, as BP often normalizes without specific antihypertensive intervention 1