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 with outpatient management and close follow-up rather than hospital admission. 1, 2

Distinguishing Urgency from Emergency

• Critical first step: Assess for signs of acute target organ damage including hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure, unstable angina, aortic dissection, acute renal failure, or eclampsia 1, 2
• Perform fundoscopic examination to assess for acute retinopathy, basic laboratory tests including renal function panel, and electrocardiogram to assess for cardiac involvement 3
• If any target organ damage is present, this becomes a hypertensive emergency requiring ICU admission and IV medications 1, 4

Blood Pressure Reduction Goals

Reduce BP gradually over 24-48 hours to avoid organ hypoperfusion 4, 3:

• Avoid rapid BP reduction: Do not reduce BP by more than 25% in the first hour 1, 2
• Target BP of 160/100 mmHg within 2-6 hours if stable 1, 2
• Then cautiously reduce to normal over the following 24-48 hours 1, 2
• Critical pitfall: Rapid and uncontrolled BP lowering can precipitate renal, cerebral, or coronary ischemia 1, 2

Medication Selection

Use oral antihypertensive agents based on patient comorbidities 1, 2:

• Preferred agents: ACE inhibitors, ARBs, or beta-blockers (shorter-acting formulations like captopril or metoprolol) 1, 2
• Start with low initial doses as these patients can be very sensitive to these agents 1
• For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2
• Avoid short-acting nifedipine due to risk of rapid, uncontrolled BP falls; use extended-release formulations instead 2
• Avoid IV medications - these are reserved for true hypertensive emergencies 2

Special Populations and Considerations

Sympathomimetic-induced hypertension (cocaine, methamphetamine):

• Exercise caution with beta-blocker use as they may worsen coronary vasoconstriction 1, 2
• Consider benzodiazepines as first-line treatment for autonomic hyperreactivity 3

Acute pain or distress:

• Many patients with acute pain may have acutely elevated BP that normalizes when pain and distress are relieved, rather than requiring specific BP intervention 1, 2

Monitoring and Follow-up

• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 2
• Arrange follow-up within one week to ensure adequate BP control 3
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 2
• Screen for secondary causes of hypertension 4, 3
• Patients with history of hypertensive urgency remain at increased risk for cardiovascular and renal disease requiring long-term management 3

What NOT to Do

• Do not admit to hospital unless there are concerning features or poor follow-up capability 3
• Do not use IV antihypertensive agents for hypertensive urgency 2
• Do not reduce BP excessively or too rapidly as this leads to complications 1, 2
• Do not use short-acting nifedipine due to unpredictable rapid BP drops 2