What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency should be managed in an outpatient setting with oral antihypertensive medications and close follow-up within one week, avoiding rapid blood pressure reduction to prevent organ hypoperfusion. 1, 2

Key Distinction from Hypertensive Emergency

The fundamental management decision hinges on whether acute target organ damage is present 1:

• Hypertensive urgency: Severe BP elevation (>180/120 mmHg) without acute organ damage—managed with oral agents outpatient 2
• Hypertensive emergency: Severe BP elevation with acute organ damage (encephalopathy, stroke, MI, pulmonary edema, aortic dissection)—requires immediate IV therapy in ICU 1

Initial Assessment

Before initiating treatment, confirm the diagnosis by 2:

• Repeated BP measurements in both arms to verify elevation
• Fundoscopic examination to assess for papilledema or hemorrhages indicating malignant hypertension
• Basic laboratory tests: renal function panel, electrolytes, urinalysis, troponins 1
• ECG to assess for cardiac involvement 2
• Physical examination focusing on neurological status, cardiovascular examination, and signs of heart failure

Oral Medication Selection

First-line oral agents include captopril, labetalol, and extended-release nifedipine 3, 1:

• Select based on patient comorbidities and current medications 2
• Use short-acting oral formulations initially to allow careful titration 2
• Avoid short-acting immediate-release nifedipine due to unpredictable rapid BP falls that can cause cardiovascular complications 3, 1

Blood Pressure Reduction Strategy

Gradual BP lowering over 24-48 hours is the appropriate approach 4:

• Controlled reduction to safer levels without risk of hypotension 3
• Rapid BP lowering is not recommended as it can lead to organ hypoperfusion and cardiovascular complications 3, 2
• Observation period of at least 2 hours after medication administration to evaluate efficacy and safety 3

Critical Management Pitfalls to Avoid

• Never use short-acting nifedipine due to uncontrolled rapid BP drops 1
• Do not aggressively lower BP in the emergency department for asymptomatic elevation 1
• Avoid hospital admission unless concerning features or poor follow-up anticipated 2
• Do not treat as hypertensive emergency without documented organ damage 1

Special Populations

Sympathomimetic intoxication (cocaine, amphetamines) requires modified approach 1, 2:

• Benzodiazepines first-line before specific antihypertensive treatment 1
• Avoid beta-blockers as they may worsen coronary vasoconstriction in cocaine-induced hypertension 2
• Alternative agents: phentolamine, clonidine, nicardipine, or nitroprusside 1

Follow-Up and Long-Term Management

Close follow-up within one week is essential 2:

• At least monthly visits until BP controlled 1
• Screen for secondary causes of hypertension 1, 2
• Address medication adherence and modifiable risk factors 2
• Educate patients about importance of adherence to prevent recurrence 2
• Patients remain at increased risk for cardiovascular and renal disease long-term 2

Monitoring After Initial Treatment

After initiating oral medication 3:

• Observe for minimum 2 hours to assess BP response
• Reassess for development of any organ damage symptoms
• Ensure patient has clear follow-up plan before discharge
• Provide specific instructions about when to seek emergency care