What is the recommended treatment for hypertensive urgency?

Treatment of Hypertensive Urgency

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), initiate oral antihypertensive medication with first-line agents being captopril, labetalol, or extended-release nifedipine, aiming to reduce systolic BP by no more than 25% within the first hour, then to <160/100 mmHg over the next 2-6 hours. 1, 2

Critical Distinction: Urgency vs Emergency

Before initiating treatment, you must distinguish hypertensive urgency from emergency:

• Hypertensive urgency is severe BP elevation (>180/120 mmHg) in otherwise stable patients without acute or impending target organ damage 1, 2
• Hypertensive emergency requires evidence of acute target organ damage (hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left ventricular failure, unstable angina, aortic dissection, acute renal failure) and mandates immediate IV therapy in an ICU setting 1, 2
• Look specifically for: retinopathy with acute microangiopathy, encephalopathy symptoms, chest pain, acute heart failure signs, or acute renal deterioration 2

First-Line Oral Medications

Three preferred oral agents are recommended by the European Society of Cardiology and American College of Cardiology 1:

Captopril (ACE Inhibitor)

• Particularly useful in hypertensive urgencies with high plasma renin activity 1
• Must start at very low doses to prevent sudden BP drops, as patients are often volume depleted from pressure natriuresis 1
• Contraindicated in pregnancy and bilateral renal artery stenosis 1

Labetalol (Combined Alpha and Beta-Blocker)

• Dual mechanism of action provides effective BP control 1, 2
• Contraindicated in reactive airways disease, COPD, second- or third-degree heart block, bradycardia, and decompensated heart failure 1
• Use with caution in sympathomimetic-induced hypertension (cocaine, amphetamines) 1

Extended-Release Nifedipine (Calcium Channel Blocker)

• Only use extended-release formulations 1, 2
• Never use short-acting nifedipine - it causes rapid, uncontrolled BP falls that can precipitate stroke and death 1, 2

Blood Pressure Reduction Goals

Follow this stepwise approach 1, 2:

1. First hour: Reduce systolic BP by no more than 25%
2. Next 2-6 hours: If stable, aim for BP <160/100 mmHg
3. Following 24-48 hours: Cautiously normalize BP to goal

Avoid excessive BP falls that may precipitate renal, cerebral, or coronary ischemia 2

Monitoring and Observation

• Observe the patient for at least 2 hours after initiating oral medication to evaluate BP-lowering efficacy and safety 1, 2
• Avoid rapid and uncontrolled BP lowering, as it can lead to further complications 2

Special Populations and Situations

Black Patients

• Initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2

Cocaine/Amphetamine Intoxication

• Initiate benzodiazepines first 3
• If additional BP-lowering is needed, consider phentolamine, nicardipine, or nitroprusside 3
• Clonidine can be used for its sympathicolytic and sedative effects, but only after benzodiazepines 3
• Beta-blockers (including labetalol) are relatively contraindicated as they don't effectively reduce coronary vasoconstriction 3

Coronary Ischemia

• Use nitroglycerin and aspirin in addition to benzodiazepines if cocaine-related 3

Pain or Distress-Related Hypertension

• Many patients with acute pain or distress have acutely elevated BP that will normalize when pain and distress are relieved, rather than requiring specific antihypertensive intervention 2

Critical Pitfalls to Avoid

• Never use IV medications for hypertensive urgency - these are reserved for true hypertensive emergencies with acute target organ damage 1, 2
• Never use short-acting nifedipine due to risk of stroke and death from uncontrolled BP falls 1, 2
• Avoid treating asymptomatic severe hypertension as an emergency - most patients have urgency, not emergency, and aggressive IV treatment can cause harm 1
• Don't use clonidine as first-line therapy - it causes significant CNS adverse effects (sedation, dizziness, cognitive impairment), especially in older adults 1
• Avoid abrupt discontinuation of clonidine if used, as it can induce rebound hypertensive crisis 1

Follow-Up and Long-Term Management

• Address medication compliance issues, as many hypertensive urgencies result from non-adherence 1
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1
• Patients with previous hypertensive urgency remain at increased cardiovascular and renal risk compared to hypertensive patients without such events 3
• Improving adherence and persistence with treatment is crucial for long-term outcomes 3