What is the treatment approach for hypertensive urgency vs hypertensive emergency?

Hypertensive Urgency vs Hypertensive Emergency: Treatment Approach

Critical Distinction

The presence of acute target organ damage—not the absolute blood pressure number—is the sole factor that distinguishes hypertensive emergency from urgency and dictates completely different treatment pathways. 1

Hypertensive Emergency

• Definition: BP >180/120 mmHg WITH evidence of new or worsening target organ damage 1, 2
• Mortality: 79% at 1 year if untreated, with median survival of only 10.4 months 2
• Target organ damage includes: 1, 2
  • Neurologic: hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke
  • Cardiac: acute MI, acute left ventricular failure with pulmonary edema, unstable angina
  • Vascular: aortic dissection or aneurysm
  • Renal: acute kidney injury, thrombotic microangiopathy
  • Ophthalmologic: malignant hypertension with papilledema, retinal hemorrhages
  • Obstetric: severe preeclampsia or eclampsia

Hypertensive Urgency

• Definition: BP >180/120 mmHg WITHOUT acute or impending target organ damage 1
• Common cause: Medication noncompliance or inadequate treatment 1
• Prognosis: Can be managed without hospitalization in most cases 1

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Management of Hypertensive Emergency

Immediate Actions

Admit to ICU immediately for continuous arterial BP monitoring and parenteral therapy (Class I recommendation, Level B-NR). 1, 2

Blood Pressure Reduction Targets

For compelling conditions (aortic dissection): 1

• Reduce SBP to <140 mmHg within first hour
• Further reduce to <120 mmHg with heart rate <60 bpm immediately

For non-compelling conditions: 1, 3

• Reduce MAP by no more than 25% within first hour
• Then if stable, reduce to 160/100 mmHg over next 2-6 hours
• Cautiously normalize over following 24-48 hours

Critical pitfall: Avoid excessive acute drops >70 mmHg systolic, as this precipitates cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation. 1, 3

First-Line IV Medications

Nicardipine (preferred for most situations): 1, 3, 4

• Initial dose: 5 mg/hr IV infusion
• Titrate by 2.5 mg/hr every 15 minutes
• Maximum: 15 mg/hr
• Advantages: Leaves cerebral blood flow intact, does not increase intracranial pressure 3

Labetalol (excellent for renal involvement, cerebrovascular events): 1, 3

• 0.25-0.5 mg/kg IV bolus, OR
• 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/hr maintenance
• Contraindications: 2nd/3rd degree AV block, systolic heart failure, asthma, bradycardia 3

Specific clinical scenarios: 3

• Acute pulmonary edema: Nitroglycerin IV (5-10 mcg/min, titrate every 5-10 minutes) or sodium nitroprusside
• Acute coronary syndrome: Nitroglycerin with target SBP <140 mmHg immediately
• Aortic dissection: Esmolol plus nitroprusside/nitroglycerin, target SBP <120 mmHg and HR <60 bpm immediately
• Eclampsia/preeclampsia: Hydralazine, labetalol, or nicardipine
• Acute renal failure: Clevidipine, fenoldopam, or nicardipine

Monitoring Requirements

• Continuous arterial line BP monitoring 3
• Continuous cardiac monitoring 1
• Frequent neurological assessments 3
• Serial renal function, electrolytes, troponins as indicated 2

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Management of Hypertensive Urgency

Treatment Setting

Do NOT admit to hospital or use IV medications—manage with oral agents and outpatient follow-up. 1, 3

First-Line Oral Medications

Preferred agents (avoid rapid BP reduction): 1, 3

• Captopril (ACE inhibitor): Start at very low doses due to risk of sudden BP drops in volume-depleted patients 3
• Labetalol (combined alpha/beta-blocker): Dual mechanism of action 3
• Extended-release nifedipine (calcium channel blocker): ONLY extended-release formulation 1, 3

NEVER use short-acting nifedipine—causes rapid, uncontrolled BP falls leading to stroke and death. 1, 3

Blood Pressure Reduction Goals

• Reduce SBP by no more than 25% within first hour 1, 3
• Aim for BP <160/100 mmHg over next 2-6 hours 1, 3
• Target <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 2

Observation and Follow-up

• Observe for at least 2 hours after initiating oral medication to evaluate BP-lowering efficacy and safety 3
• Schedule follow-up within 2-4 weeks to assess response 2
• Address medication adherence issues, as noncompliance is the most common trigger 3
• Screen for secondary hypertension causes (20-40% of cases) 3, 2

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Special Considerations

Stroke Management

Acute ischemic stroke: 3, 2

• Avoid BP reduction within first 5-7 days unless BP >220/120 mmHg
• If eligible for reperfusion therapy: maintain BP <180/105 mmHg for first 24 hours
• If not receiving reperfusion with BP ≥220/110 mmHg: lower by approximately 15% during first 24 hours

Acute hemorrhagic stroke: 3, 2

• If SBP <220 mmHg: do not lower immediately
• If SBP ≥220 mmHg: carefully lower to 140-180 mmHg within 6 hours to prevent hematoma expansion

Cocaine/Amphetamine Intoxication

• Initiate benzodiazepines first for autonomic hyperreactivity 3
• Avoid beta-blockers alone (unopposed alpha stimulation) 3

Common Pitfalls to Avoid

• Do not treat asymptomatic severe hypertension as an emergency—most patients have urgency, not emergency, and aggressive IV treatment causes harm 3
• Do not use clonidine in older adults—significant CNS adverse effects including cognitive impairment 3
• Do not apply outpatient BP goals to acute inpatient management—limited evidence for aggressive inpatient BP lowering, may cause hypotension-related complications 2
• Remember that many patients with acute pain or distress have transiently elevated BP that normalizes when underlying condition is treated—avoid treating the BP number alone 2