What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

Definition and Key Distinction

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), treat with oral antihypertensive medications and avoid intravenous agents, which are reserved exclusively for hypertensive emergencies. 1

• Hypertensive urgency is distinguished from emergency by the absence of acute target organ damage such as hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left ventricular failure, unstable angina, aortic dissection, or acute renal failure 1
• Many patients with acute pain or distress may have transiently elevated BP that normalizes when the underlying stressor is relieved, rather than requiring specific antihypertensive intervention 1

Blood Pressure Reduction Goals

Reduce systolic BP by no more than 25% within the first hour, then cautiously aim for 160/100 mmHg over the next 2-6 hours, with gradual normalization over 24-48 hours. 1, 2

• Excessive or rapid BP reduction can precipitate renal, cerebral, or coronary ischemia 1
• The controlled, gradual approach prevents cardiovascular complications while safely lowering BP 2

First-Line Oral Medications

Use one of three preferred oral agents: captopril, labetalol, or extended-release nifedipine. 1, 2

Captopril (ACE Inhibitor)

• Start at very low doses due to potential sensitivity, especially in volume-depleted patients from pressure natriuresis 1
• Effective first-line option with predictable BP reduction 2

Labetalol (Combined Alpha and Beta-Blocker)

• Dual mechanism provides controlled BP reduction 1, 2
• Contraindicated in 2nd or 3rd degree AV block, systolic heart failure, asthma, and bradycardia 2
• Use caution in patients with acute BP elevation from sympathomimetics (methamphetamine, cocaine) 1

Extended-Release Nifedipine (Calcium Channel Blocker)

• Only use extended-release formulations 1, 2
• Never use short-acting nifedipine due to risk of rapid, uncontrolled BP falls that can cause stroke and death 1, 2

Special Population Considerations

• For Black patients, initial treatment should include a diuretic or calcium channel blocker, either alone or combined with a RAS blocker 1
• For patients with suspected cocaine or methamphetamine intoxication, initiate benzodiazepines first before antihypertensives 2

Monitoring Requirements

Observe the patient for at least 2 hours after initiating oral medication to evaluate BP-lowering efficacy and safety. 1, 2

• Arrange appropriate outpatient follow-up rather than hospital admission 1
• Address medication compliance issues, which are frequently 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

• Do not use intravenous medications for hypertensive urgency—these are reserved for true emergencies with acute organ damage 1, 2
• Never use short-acting nifedipine due to uncontrolled BP drops and associated mortality 1, 2
• Avoid clonidine in older adults due to significant CNS adverse effects including cognitive impairment; reserve for specific situations like sympathomimetic intoxication 2
• Do not use GTN patches due to unpredictable BP responses and inability to titrate effectively 3
• Avoid excessive BP reduction that can cause end-organ hypoperfusion 1, 4