What is the treatment plan for hypertensive emergencies vs urgencies?

Hypertensive Urgency vs Emergency: Treatment Plan

Critical Distinction

The presence or absence of acute target organ damage—not the blood pressure number itself—determines whether you have a hypertensive emergency requiring immediate IV therapy and ICU admission, or a hypertensive urgency that can be managed with oral agents and outpatient follow-up. 1, 2

Definitions

Hypertensive Emergency

• BP >180/120 mmHg WITH acute target organ damage 2
• Requires immediate intervention to prevent progressive organ failure 2
• Without treatment, carries 1-year mortality >79% and median survival of only 10.4 months 2

Hypertensive Urgency

• Severely elevated BP WITHOUT acute organ damage 2
• Can be managed with oral medications and outpatient follow-up 2
• Does not require hospital admission or IV medications 2

Target Organ Damage Assessment

Look specifically for these manifestations to differentiate emergency from urgency: 1, 2

Neurologic

• Hypertensive encephalopathy (altered mental status, headache, visual disturbances, seizures) 2
• Intracranial hemorrhage 2
• Acute ischemic stroke 2

Cardiac

• Acute myocardial infarction 2
• Acute left ventricular failure with pulmonary edema 2
• Unstable angina 2

Vascular

• Aortic dissection 2

Renal

• Acute kidney injury 2
• Thrombotic microangiopathy 2

Ophthalmologic

• Malignant hypertension with advanced retinopathy (hemorrhages, cotton wool spots, papilledema) 2

Obstetric

• Severe preeclampsia or eclampsia 2

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Management Algorithm for Hypertensive Emergency

Immediate Actions

Admit to ICU immediately for continuous arterial BP monitoring and parenteral therapy 1, 2

Blood Pressure Reduction Targets

General approach (for most hypertensive emergencies): 2

• First hour: Reduce MAP by 20-25% (or SBP by no more than 25%)
• Next 2-6 hours: If stable, reduce to 160/100 mmHg
• Next 24-48 hours: Cautiously reduce to normal

Critical warning: Avoid excessive acute drops in SBP >70 mmHg, as this may precipitate acute renal injury, cerebral ischemia, or coronary ischemia 2

Specific Condition Targets

Aortic dissection: 2

• Target SBP <120 mmHg and heart rate <60 bpm immediately
• Use esmolol plus nitroprusside/nitroglycerin

Acute pulmonary edema: 2

• Target SBP <140 mmHg immediately
• Use nitroglycerin or nitroprusside

Acute coronary syndrome: 2

• Target SBP <140 mmHg immediately
• Use nitroglycerin

Acute ischemic stroke: 2

• Do NOT lower BP if <220/120 mmHg within first 5-7 days 2
• If BP ≥220/120 mmHg: Reduce MAP by 15% within 1 hour 2
• Exception: If receiving thrombolysis, maintain BP <180/105 mmHg for first 24 hours 2

Acute intracerebral hemorrhage: 2

• If SBP ≥220 mmHg: Carefully lower to 140-160 mmHg within 6 hours 2
• If SBP <220 mmHg: Do not lower immediately 2

Hypertensive encephalopathy: 2, 3

• Reduce MAP by 20-25% within first hour
• Use IV labetalol or nicardipine

Malignant hypertension with renal failure: 2

• Reduce MAP by 20-25% over several hours
• Use IV labetalol as first-line

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First-Line IV Medications for Hypertensive Emergency

Nicardipine (Preferred for most situations)

• Dosing: Start 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr 2, 4
• Advantages: Rapid onset, easily titratable, predictable response 2
• Dilution: Each 25 mg vial diluted with 240 mL compatible IV fluid to 0.1 mg/mL 4
• Compatibility: Compatible with D5W, NS, D5NS; NOT compatible with sodium bicarbonate or lactated Ringer's 4
• Administration: Change infusion site every 12 hours if via peripheral vein 4

Labetalol (Preferred for encephalopathy, renal involvement, chronic CVD)

• Dosing: 20 mg IV bolus over 2 minutes, then 40-80 mg every 10 minutes 2, 3
• Advantages: Controlled BP reduction without reflex tachycardia 2, 3
• Best for: Hypertensive encephalopathy, malignant hypertension with renal failure 2, 3

Clevidipine

• Similar to nicardipine with rapid onset and offset 2

Sodium Nitroprusside

• Dosing: 0.25-10 mcg/kg/min IV infusion 2
• Caution: Risk of thiocyanate toxicity with prolonged use (>48-72 hours) or renal insufficiency 2
• Use with extreme caution due to toxicity concerns 5, 6

Nitroglycerin (For acute pulmonary edema or ACS)

• Dosing: 5-10 mcg/min IV, titrate by 5-10 mcg/min every 5-10 minutes 2
• Best for: Acute left ventricular failure with pulmonary edema, acute coronary syndrome 2

Esmolol (For aortic dissection)

• Use in combination with nitroprusside/nitroglycerin for aortic dissection 2

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Management Algorithm for Hypertensive Urgency

Do NOT admit to hospital or use IV medications 2

Treatment Approach

1. Initiate or adjust oral antihypertensive therapy 2
2. Arrange outpatient follow-up within 24-48 hours 2
3. Reduce BP to baseline or normal over 24-48 hours 7

Important Considerations

• Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up 2
• Rapid BP lowering may be harmful in hypertensive urgency 2
• Many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 2

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Essential Diagnostic Workup for Hypertensive Emergency

Obtain immediately to assess target organ damage: 2

Laboratory Tests

• Complete blood count (hemoglobin, platelets) - assess for microangiopathic hemolytic anemia 2
• Basic metabolic panel (creatinine, sodium, potassium) - evaluate renal function 2
• Lactate dehydrogenase (LDH) and haptoglobin - detect hemolysis in thrombotic microangiopathy 2
• Urinalysis for protein and urine sediment - identify renal damage 2
• Troponins if chest pain present - evaluate for acute coronary syndrome 2

Imaging and Other Tests

• ECG - assess for cardiac involvement 2
• Fundoscopy - look for papilledema, hemorrhages, exudates (though up to one-third may lack advanced retinopathy) 2, 3
• Chest X-ray - evaluate for pulmonary edema 2
• CT/MRI brain if neurologic symptoms - rule out stroke or hemorrhage 2
• Echocardiogram if cardiac symptoms 2

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Critical Pitfalls to Avoid

Never use short-acting nifedipine - causes unpredictable precipitous BP drops and reflex tachycardia 2, 5, 6

Do not normalize BP acutely in chronic hypertension - patients have altered cerebral autoregulation; acute normotension can cause cerebral, renal, or coronary ischemia 1, 2, 3

Do not treat the BP number alone - assess for true target organ damage before initiating aggressive therapy 2

Avoid excessive acute drops in SBP (>70 mmHg) - may precipitate acute renal injury, cerebral ischemia, or coronary ischemia 2

Do not lower BP in acute ischemic stroke unless >220/120 mmHg - premature BP reduction can worsen cerebral ischemia 2

Do not use hydralazine, immediate-release nifedipine, or nitroglycerin as first-line - associated with significant toxicities and/or side effects 5, 6

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Post-Stabilization Management

Screen for secondary hypertension causes - found in 20-40% of malignant hypertension cases (renal artery stenosis, pheochromocytoma, primary aldosteronism) 2

Address medication non-compliance - the most common trigger for hypertensive emergencies 2

Transition to oral therapy - use combination of RAS blockers, calcium channel blockers, and diuretics 2

Target long-term SBP 120-129 mmHg - to reduce cardiovascular risk 2

Ensure close outpatient follow-up - patients with prior hypertensive emergencies remain at significantly elevated cardiovascular risk 2, 3