Management of Hypertensive Urgency
Hypertensive urgency should be managed in the outpatient setting with oral antihypertensive medications and gradual blood pressure reduction over 24-48 hours, avoiding rapid lowering that can cause organ hypoperfusion. 1, 2
Definition and Initial Assessment
Hypertensive urgency is defined as severely elevated blood pressure (>180/120 mmHg) without acute target organ damage 1, 2. The critical distinction from hypertensive emergency determines the entire management approach—urgencies are managed outpatient with oral agents, while emergencies require ICU admission with IV therapy 2.
Confirm the diagnosis with:
- Repeated blood pressure measurements in both arms to verify elevation 1
- Fundoscopic examination specifically looking for retinal hemorrhages, cotton wool spots, or papilledema (which would indicate malignant hypertension and change management) 1
- Basic laboratory tests including renal function panel, complete blood count to exclude thrombotic microangiopathy, and electrocardiogram 1
Rule out target organ damage by assessing for:
- Altered mental status, headache with vomiting, visual disturbances, or seizures (suggests hypertensive encephalopathy) 1
- Chest pain (suggests acute coronary syndrome or aortic dissection) 1
- Any findings that would reclassify this as a hypertensive emergency requiring immediate IV therapy 2
Treatment Strategy
Blood Pressure Reduction Goals:
- Target reduction to <160/100 mmHg over 24-48 hours 1, 3
- Avoid reducing to "normal" levels acutely, as patients with chronic hypertension have altered cerebrovascular autoregulation 1
- Gradual lowering prevents organ hypoperfusion and ischemic complications affecting the brain, kidneys, or heart 1, 3
Medication Selection
First-line oral agents recommended by the European Society of Cardiology: 1, 2
- Captopril
- Labetalol
- Extended-release nifedipine
Select based on patient comorbidities and current medications 1. Short-acting formulations are preferred initially to allow careful titration 1.
Observe the patient for at least 2 hours after medication administration to evaluate efficacy and safety 1
Critical Pitfalls to Avoid
Never use short-acting immediate-release nifedipine due to unpredictable rapid BP falls that can cause cardiovascular complications 1, 2. This is a common error that can lead to stroke and death 2.
Do not rapidly lower BP to "normal" levels—excessive acute drops can precipitate cerebral, renal, or coronary ischemia in patients with chronic hypertension 1, 3. The goal is safer levels, not normalization 1.
Avoid aggressive treatment of asymptomatic BP elevation in emergency departments—these patients do not benefit from immediate therapy and may be harmed 2.
Special Populations
For sympathomimetic intoxication (cocaine, amphetamines):
- Initiate benzodiazepines first before antihypertensive treatment 1, 2
- Never use beta-blockers as they may worsen coronary vasoconstriction 1, 2
Follow-Up and Long-Term Management
Close follow-up within one week is essential to ensure adequate blood pressure control 1, 2. Hospital admission is generally not required unless there are concerning features or poor follow-up 1, 2.
Screen for secondary causes of hypertension in all patients with hypertensive urgency 1, 2.
Address medication adherence and modifiable risk factors, as patients with a history of hypertensive urgency remain at increased risk for cardiovascular and renal disease 1.
Note: One randomized controlled trial found that resting alone was as effective as antihypertensive medication (telmisartan) in reducing BP over 2 hours in hypertensive urgency patients 4. However, current guidelines prioritize oral antihypertensive therapy with close follow-up to ensure sustained control and prevent recurrence 1, 2.