What medications are used to treat hypertensive urgency?

Medications for Hypertensive Urgency

Critical Distinction: Urgency vs Emergency

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), use oral antihypertensive medications with gradual BP reduction, NOT intravenous agents. 1, 2

• Hypertensive urgency is defined as severe BP elevation without evidence of new or progressive target organ damage (no encephalopathy, stroke, acute heart failure, acute renal failure, or retinopathy) 1, 2
• IV medications are reserved exclusively for true hypertensive emergencies with acute end-organ damage and should be avoided in urgency 2

First-Line Oral Medications

The three preferred oral agents are captopril, labetalol, and extended-release nifedipine. 1, 2

Captopril (ACE Inhibitor)

• Start at very low doses to prevent sudden BP drops, as patients are often volume depleted from pressure natriuresis 1
• Particularly useful in hypertensive urgencies associated with high plasma renin activity 3
• Contraindicated in pregnancy and bilateral renal artery stenosis 3

Labetalol (Combined Alpha and Beta-Blocker)

• Dual mechanism of action provides effective BP control 1, 2
• Contraindicated in reactive airways disease, COPD, second- or third-degree heart block, bradycardia, and decompensated heart failure 3
• May worsen heart failure 3

Extended-Release Nifedipine (Calcium Channel Blocker)

• Only use extended-release formulations—short-acting nifedipine is absolutely contraindicated due to risk of rapid, uncontrolled BP falls causing stroke and death 1, 2
• Effective for gradual BP reduction 1

Blood Pressure Reduction Goals

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

• Excessive or rapid BP reduction can precipitate renal, cerebral, or coronary ischemia 2
• Observe patients for at least 2 hours after initiating medication to evaluate efficacy and safety 1, 2

Special Populations and Situations

Black Patients

• Initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2

Autonomic Hyperreactivity (Cocaine/Amphetamine Intoxication)

• Initiate benzodiazepines first 1
• Clonidine may be considered as a last-line option in these specific situations, but avoid in older adults due to significant CNS adverse effects including cognitive impairment 1
• Beta-blockers should be used with caution in sympathomimetic-induced hypertension 2

Coronary Ischemia

• Nitroglycerin and aspirin are recommended 1

Critical Pitfalls to Avoid

Never use short-acting nifedipine—it causes uncontrolled BP drops leading to stroke and death. 1, 2

• Avoid IV medications in hypertensive urgency; they are only for emergencies 2
• Do not use clonidine as first-line therapy due to CNS adverse effects, especially in elderly patients 1
• If clonidine is used, never abruptly discontinue it as this can induce rebound hypertensive crisis 1
• Avoid rapid BP reduction that exceeds the 25% in first hour guideline 2

Follow-Up and Compliance

• Many hypertensive urgencies result from medication non-adherence—address compliance issues directly 1
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1
• Arrange appropriate outpatient follow-up rather than hospital admission for uncomplicated urgency 2

Alternative Oral Agents (Second-Line)

• ARBs may be used with low initial doses due to potential sensitivity 2
• Beta-blockers can be considered but use caution in sympathomimetic-induced hypertension 2
• Diuretics are appropriate, especially in black patients 2