What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency should be managed with oral antihypertensive medications in the outpatient setting, with blood pressure reduced by no more than 25% within the first hour, then to 160/100 mmHg over 2-6 hours—there is no indication for emergency department referral or hospitalization in stable patients without acute target organ damage. 1, 2

Definition and Differentiation from Emergency

• Hypertensive urgency is defined as severe blood pressure elevation (>180/120 mmHg) without evidence of new or progressive acute target organ damage 1, 2
• This differs critically from hypertensive emergency, which involves acute organ damage (hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, or eclampsia) and requires immediate IV therapy in an intensive care unit 1
• The actual blood pressure level may be less important than the rate of rise—patients with chronic hypertension often tolerate higher pressures than previously normotensive individuals 1

Initial Assessment

• Confirm blood pressure measurement using proper technique to exclude pseudoresistance and measurement error 2
• Screen specifically for symptoms indicating acute target organ damage: new neurological deficits, chest pain, dyspnea, altered mental status, visual changes, or severe headache with focal findings 2
• Evaluate for secondary causes of hypertension including primary aldosteronism, chronic kidney disease, renal artery stenosis, pheochromocytoma, and obstructive sleep apnea 2
• Identify and discontinue contributing substances: NSAIDs, sympathomimetics (decongestants, amphetamines, cocaine), stimulants, oral contraceptives, and licorice 2
• Assess medication adherence, as many hypertensive urgencies result from withdrawal from or non-compliance with antihypertensive therapy 1, 3

Oral Medication Options

First-line oral agents include: 3

• Captopril (ACE inhibitor): Start at very low doses to prevent sudden blood pressure drops, as patients are often volume depleted from pressure natriuresis 3
• Labetalol (combined alpha and beta-blocker): Dual mechanism of action makes this suitable for most patients 3
• Extended-release nifedipine (calcium channel blocker): Use only the retard/extended-release formulation 3

Critical Contraindication

• Short-acting immediate-release nifedipine must never be used—it causes rapid, uncontrolled blood pressure falls that can precipitate stroke and death 3

Blood Pressure Reduction Goals and Monitoring

• Reduce systolic blood pressure by no more than 25% within the first hour 1, 2, 3
• Then, if stable, reduce to 160/100 mmHg within the next 2-6 hours 1, 2
• Cautiously normalize blood pressure over the following 24-48 hours 1
• Observe patients for at least 2 hours after initiating oral medication to evaluate blood pressure-lowering efficacy and safety 3
• Avoid rapid blood pressure reduction, which can lead to cerebral, cardiac, or renal hypoperfusion 2

Special Clinical Scenarios

• Amphetamine or cocaine intoxication: Administer benzodiazepines first, followed by antihypertensive therapy only if needed after sedation 2, 3
• Suspected medication non-adherence: Provide counseling and motivational interviewing; reinstitute or intensify previous antihypertensive regimen 1, 2
• Anxiety-related hypertension: Treat anxiety as applicable rather than aggressively lowering blood pressure 1

Follow-up Care

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

Escalation Criteria to Emergency Management

Admit to intensive care unit for IV antihypertensive therapy if: 1, 3

• Signs of acute end-organ damage develop during observation
• Blood pressure remains severely elevated despite oral therapy
• Patient develops symptoms of hypertensive emergency during monitoring

When IV therapy becomes necessary, preferred agents include nicardipine (initial 5 mg/hr, increasing by 2.5 mg/hr every 5 minutes to maximum 15 mg/hr), labetalol, or clevidipine 1, 4