What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), initiate oral antihypertensive medication with a goal of reducing systolic blood pressure by no more than 25% within the first hour, then to 160/100 mmHg over 2-6 hours, followed by cautious normalization over 24-48 hours. 1

Distinguishing Urgency from Emergency

Before treating, you must assess for acute target organ damage to differentiate hypertensive urgency from emergency:

• Look for: hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina, aortic dissection, acute renal failure, or retinopathy with acute microangiopathy 1
• If any present: This is a hypertensive emergency requiring IV medications in an ICU setting, not oral therapy 2
• If none present: Proceed with oral medication management for hypertensive urgency 1

First-Line Oral Medications

Select from these evidence-based options:

ACE Inhibitors

• Captopril is a first-line choice but must be started at very low doses due to potential for sudden BP drops, as patients are often volume depleted from pressure natriuresis 2, 3
• Onset of action: 0.5-1 hour 3

Combined Alpha/Beta Blockers

• Labetalol (oral) provides dual mechanism of action and is highly effective 1, 2
• Maximal effect at 2-4 hours 3
• Contraindicated in 2nd/3rd degree AV block, systolic heart failure, asthma, and bradycardia 2

Calcium Channel Blockers

• Extended-release nifedipine is acceptable ONLY in extended-release formulation 1, 2
• Never use short-acting nifedipine - it causes rapid, uncontrolled BP falls leading to stroke and death 1, 2
• Onset: 0.5-1 hour with appropriate formulation 3

Special Population Considerations

• Black patients: Initiate with a diuretic or calcium channel blocker, either alone or combined with a RAS blocker 1
• Cocaine/methamphetamine intoxication: Use benzodiazepines first; avoid beta-blockers due to unopposed alpha stimulation 2
• Acute pain/distress: Many patients have elevated BP that normalizes when pain is relieved - address the underlying cause first 1

Critical Monitoring Protocol

• Observe for at least 2 hours after initiating medication to evaluate BP lowering efficacy and safety 1, 2
• Monitor for excessive BP reduction that can precipitate renal, cerebral, or coronary ischemia 1
• Avoid intravenous medications - these are reserved exclusively for true hypertensive emergencies with organ damage 1, 2

Common Pitfalls to Avoid

• Do not reduce BP too rapidly - this causes more harm than benefit through ischemic complications 1, 2
• Do not admit to hospital unless there is acute target organ damage; outpatient management with close follow-up is appropriate 1
• Do not use sublingual nifedipine under any circumstances due to unpredictable, dangerous BP drops 1, 2
• Do not use IV medications for urgency - oral therapy is the standard of care 1, 2

Follow-Up Management

• Address medication non-compliance, which is the most common underlying cause of hypertensive urgency 1, 2
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 2
• Ensure continued BP control with appropriate long-term antihypertensive regimen 1