What is the recommended management for hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency should be managed with oral antihypertensive medications and outpatient follow-up, NOT with IV medications or hospital admission, as these patients lack acute target organ damage and rapid BP reduction can cause harm. 1, 2

Definition and Differentiation from Emergency

• Hypertensive urgency is defined as severely elevated BP (typically >180/120 mmHg) WITHOUT acute target organ damage, distinguishing it from hypertensive emergency which requires immediate ICU admission and IV therapy 1, 2
• The presence or absence of acute organ damage—not the absolute BP number—is the critical distinguishing feature 3
• Assess for signs of target organ damage including hypertensive encephalopathy, intracranial hemorrhage, acute MI, acute left ventricular failure, unstable angina, aortic dissection, or acute renal failure 2
• Patients often present with severe headache, shortness of breath, epistaxis, or severe anxiety 2

Initial Assessment

• Confirm BP >180/120 mmHg with repeat measurements in both arms 1, 3
• Perform focused examination for subtle signs of organ damage: brief neurologic exam, cardiac assessment, fundoscopic exam (looking for hemorrhages, exudates, papilledema) 1, 3
• Obtain diagnostic testing if indicated: physical examination, fundoscopy, renal panel, ECG 1
• Many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated—avoid treating the BP number alone 3, 2

Blood Pressure Targets

• Reduce SBP by no more than 25% within the first hour, then cautiously reduce to 160/100 mmHg within 2-6 hours if stable 2
• Further reduction to normal should occur over 24-48 hours 2
• Avoid excessive BP falls that may precipitate renal, cerebral, or coronary ischemia, as patients with chronic hypertension have altered autoregulation 3, 2

Medication Selection

First-Line Oral Agents

• ACE inhibitors, ARBs, or beta-blockers using low initial doses due to potential sensitivity 2
• Captopril is particularly useful in hypertensive urgencies associated with high plasma renin activity (contraindicated in pregnancy and bilateral renal artery stenosis) 2
• Labetalol (contraindicated in reactive airways disease, COPD, second- or third-degree heart block, bradycardia, decompensated heart failure) 2

Special Population Considerations

• For Black patients: initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2
• Use beta-blockers with caution in sympathomimetic-induced hypertension (methamphetamine, cocaine) 2

Critical Medications to AVOID

• Do NOT use short-acting nifedipine due to risk of rapid, uncontrolled BP falls 2
• Do NOT use IV medications—these are reserved for true hypertensive emergencies 2
• Avoid hydralazine and sodium nitroprusside as first-line therapy due to significant toxicities 4

Monitoring and Follow-up

• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 2
• Arrange appropriate outpatient follow-up to ensure continued BP control 1, 2
• Address medication compliance issues, which are often the underlying cause of hypertensive urgency 2
• Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and rapid BP lowering may be harmful 3

Common Pitfalls to Avoid

• Do not admit to hospital or use IV medications—hypertensive urgency does not require inpatient admission 1, 2
• Do not lower BP too rapidly—this can lead to cerebral, renal, or coronary ischemia 2
• Do not apply outpatient BP goals to acute management—evidence for aggressive inpatient BP lowering is limited and may cause harm 3
• Do not treat asymptomatic elevated BP in the absence of true urgency criteria—many patients have transiently elevated BP from pain or distress 3