What is the management of hypertensive urgency?

From the Guidelines

Hypertension urgency management requires prompt but controlled blood pressure reduction over 24-48 hours, starting with oral medications such as labetalol, amlodipine, or captopril, and targeting a 20-25% reduction in the first 24 hours. The management of hypertensive urgency is focused on preventing target organ damage while avoiding rapid blood pressure drops that can cause organ damage 1. Key considerations in managing hypertensive urgency include:

• Starting with oral medications rather than IV agents to avoid rapid drops in blood pressure
• Using first-line medications such as labetalol (200-400 mg orally every 2-3 hours), amlodipine (5-10 mg once daily), or captopril (25 mg orally, which can be repeated)
• Monitoring blood pressure every 30-60 minutes initially, then every 2-4 hours as it stabilizes
• Targeting a 20-25% reduction in the first 24 hours, rather than immediate normalization
• Observing patients for several hours to ensure medication effectiveness and absence of side effects
• Transitioning to a long-term regimen with follow-up within one week
• Addressing underlying causes such as medication non-adherence, pain, or anxiety, and emphasizing lifestyle modifications including sodium restriction, weight management, and limiting alcohol alongside pharmacological treatment 1. It is essential to differentiate hypertensive urgency from emergency, as the absence of acute end-organ damage allows for a more measured approach in urgency cases 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Hypertensive Urgency

• Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease 2.
• Hypertensive urgencies can usually be managed with oral agents, such as oral nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 2.
• The goal of treatment is to reduce the blood pressure to baseline or normal over a period of 24-48 hours 3.
• Angiotensin-converting enzyme inhibitors have been shown to have a superior effect in treating hypertensive urgencies, with a lower frequency of adverse effects compared to calcium channel blockers 4.

Treatment Options

• Oral nifedipine is considered an alternative first-line therapy for hypertensive emergencies, including those presenting with pre-eclampsia 5.
• Clevidipine is endorsed by guidelines as a first-line treatment option for blood pressure reduction in acute ischemic stroke and may be considered for use in intracranial hemorrhage 5.
• Enalaprilat can be considered for use in treating hypertensive heart failure, although data supporting its use remains limited 5.
• Other treatment options for hypertensive urgency include clonidine, labetalol, prazosin, and nimodipine 2.

Important Considerations

• The management of hypertensive urgency differs from that of hypertensive emergency, which requires immediate treatment with intravenous antihypertensive medications 3, 6.
• An appreciation of cerebral autoregulation is key and should underpin treatment decisions for hypertensive emergencies and urgencies 6.
• The choice of treatment should be based on the individual patient's condition and medical history, as well as the presence of any target organ damage 2, 6.