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 in the outpatient setting with close follow-up within one week, avoiding rapid or excessive BP reduction that could precipitate organ ischemia. 1, 2

Definition and Diagnostic Distinction

• Hypertensive urgency is defined as severe BP elevation (typically >180/120 mmHg) in otherwise stable patients without acute or impending target organ damage 1, 2
• The critical distinction from hypertensive emergency requires assessment for signs of acute organ damage including: hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, or eclampsia 2, 3
• Many patients presenting with elevated BP in emergency departments have acute pain or distress causing transient elevation that will normalize when the underlying trigger is relieved, rather than requiring specific antihypertensive intervention 1

Blood Pressure Reduction Goals and Timeline

The recommended approach is gradual BP reduction over 24-48 hours, NOT immediate reduction: 1, 2

• Reduce SBP by no more than 25% within the first hour 1
• Then, if stable, reduce to 160/100 mmHg within the next 2-6 hours 1
• Finally, cautiously reduce to normal during the following 24-48 hours 1, 4

This gradual approach is essential because excessive or rapid BP lowering can precipitate renal, cerebral, or coronary ischemia 2, 5

Treatment Setting and Monitoring

• Hospital admission is NOT required for hypertensive urgency; outpatient management with oral medications is appropriate 1, 2
• Patients should be observed for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 2
• Intravenous medications should be avoided in hypertensive urgency and are reserved exclusively for true hypertensive emergencies 2, 6

Medication Selection

Oral antihypertensive agents are the cornerstone of treatment: 1, 2

• ACE inhibitors, ARBs, or beta-blockers (shorter-acting formulations like captopril or metoprolol) are recommended as first-line options 1, 2
• Use low initial doses because these patients can be very sensitive to antihypertensive agents 1
• Select medications based on the patient's comorbidities and baseline medication regimen 5
• For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2

Critical Medication Pitfalls to Avoid

• Short-acting nifedipine should NOT be used due to risk of rapid, uncontrolled BP falls; use extended-release formulations instead 2
• Beta-blockers should be avoided in patients with hypertension precipitated by sympathomimetics (methamphetamine or cocaine), as they may worsen coronary vasoconstriction 1, 3, 5
• For cocaine-induced hypertension, benzodiazepines are first-line treatment 5

Follow-up and Long-term Management

• Close follow-up within one week is essential to ensure adequate BP control 2, 5
• Many patients with hypertensive urgency have withdrawn from or are noncompliant with antihypertensive therapy, making medication adherence counseling critical 1, 2
• Patients should be screened for secondary causes of hypertension 3, 5
• These patients remain at increased risk for cardiovascular and renal disease despite resolution of the acute episode 5

Common Clinical Pitfalls

• Do not treat hypertensive urgency as an emergency: The absence of target organ damage means aggressive IV therapy and ICU admission are inappropriate and potentially harmful 1, 2
• Avoid excessive BP reduction: Rapid drops can cause organ hypoperfusion, particularly in patients with chronic hypertension who have adapted to higher baseline pressures 1, 5
• Confirm true hypertensive urgency: Repeat BP measurements in both arms and rule out white coat effect or pain-related transient elevations before initiating treatment 1, 5