What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

For hypertensive urgency (severe BP elevation >180/120 mmHg without acute target organ damage), use oral antihypertensive medications with gradual blood pressure reduction—reduce systolic BP by no more than 25% within the first hour, then aim for 160/100 mmHg over 2-6 hours, avoiding rapid drops that can precipitate ischemic complications. 1

Definition and Distinction from Emergency

• Hypertensive urgency is defined as severe blood pressure elevation (typically >180/120 mmHg) in otherwise stable patients without acute or impending target organ damage 1
• The critical distinction from hypertensive emergency is the absence of acute microangiopathy, 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 transiently elevated blood pressure that normalizes when the underlying stressor is relieved, rather than requiring specific antihypertensive intervention 1

Treatment Setting and Approach

• Oral medications are the appropriate treatment modality—intravenous medications should be avoided in hypertensive urgency and are reserved exclusively for true hypertensive emergencies 1, 2
• Patients can be managed with oral medication according to standard drug treatment algorithms with careful outpatient follow-up rather than hospital admission 1
• The therapeutic goal is controlled blood pressure reduction to safer levels without risk of hypotension or precipitating renal, cerebral, or coronary ischemia 1, 2

Blood Pressure Reduction Goals

• First hour: Reduce systolic blood pressure by no more than 25% 1, 2
• Next 2-6 hours: If stable, aim for BP <160/100 mmHg 1, 2
• Following 24-48 hours: Cautiously reduce to normal levels 1
• Rapid and uncontrolled or excessive blood pressure lowering is contraindicated as it can lead to cardiovascular complications including stroke and death 2

First-Line Oral Medication Options

ACE Inhibitors

• Captopril is a first-line oral option for hypertensive urgency 1, 2
• Must be started at very low doses to prevent sudden blood pressure drops, as patients are often volume depleted from pressure natriuresis 2

Combined Alpha and Beta-Blockers

• Labetalol (oral formulation) provides dual mechanism of action and is suitable for most patients with hypertensive urgency 1, 2

Calcium Channel Blockers

• Extended-release nifedipine is an acceptable option when using the retard/extended-release formulation only 1, 2
• Short-acting nifedipine should NEVER be used due to rapid, uncontrolled blood pressure falls that can cause cardiovascular complications, including stroke and death 1, 2

Special Population Considerations

• For Black patients with hypertensive urgency, initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 1
• Use caution with beta-blocker use in patients with acute and severe increases in blood pressure precipitated by sympathomimetics such as methamphetamine or cocaine 1

Monitoring Requirements

• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate blood pressure lowering efficacy and safety 1, 2
• Arrange appropriate follow-up to ensure continued blood pressure control 1
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 1, 2
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 2

Critical Pitfalls to Avoid

• Never use short-acting nifedipine (sublingual or immediate-release)—this is associated with uncontrolled rapid BP drops and cardiovascular complications 1, 2
• Avoid intravenous medications—these are inappropriate for hypertensive urgency and reserved for emergencies with acute end-organ damage 1, 2
• Do not reduce BP too rapidly—excessive falls in pressure may precipitate renal, cerebral, or coronary ischemia 1, 2
• Do not allow patients to move to erect position unmonitored until their ability to do so is established, as postural hypotension can occur 1