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 the goal of reducing systolic blood pressure 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

• Hypertensive urgency is severe BP elevation (>180/120 mmHg) in stable patients without acute or progressive target organ damage 1, 2
• Hypertensive emergency requires evidence of acute end-organ damage (encephalopathy, stroke, acute MI, pulmonary edema, aortic dissection, acute renal failure) and mandates immediate IV therapy in an ICU setting 1, 2
• Assess for signs of target organ damage before initiating treatment—this determines whether oral or IV therapy is appropriate 2

First-Line Oral Medications

Three preferred oral agents are recommended for hypertensive urgency: 1, 2

Captopril (ACE Inhibitor)

• Particularly useful when high plasma renin activity is suspected 2
• 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 2

Labetalol (Combined Alpha and Beta-Blocker)

• Dual mechanism of action provides effective BP control 1, 2
• Contraindicated in reactive airways disease, COPD, 2nd/3rd degree heart block, bradycardia, and decompensated heart failure 2
• Use with caution in sympathomimetic-induced hypertension (cocaine, amphetamines) 2

Extended-Release Nifedipine (Calcium Channel Blocker)

• Only the extended-release formulation should be used 1, 2
• Short-acting nifedipine should NEVER be used due to risk of rapid, uncontrolled BP falls that can cause stroke and death 1, 2

Alternative Agents for Specific Situations

For Black Patients

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

For Cocaine/Amphetamine Intoxication

• Initiate benzodiazepines first 1
• Avoid beta-blockers due to risk of unopposed alpha-stimulation 2
• If additional BP lowering needed after benzodiazepines, consider phentolamine, nicardipine, or nitroprusside 1

Clonidine (Reserved for Limited Use)

• Not a first-line agent due to significant CNS adverse effects (sedation, cognitive impairment), especially in older adults 1
• Reserved for specific situations: autonomic hyperreactivity from cocaine/amphetamine intoxication or when first-line agents have failed 1
• Abrupt discontinuation can cause rebound hypertensive crisis—must be tapered carefully 1

Blood Pressure Reduction Goals and Timeline

Follow this stepwise approach: 1, 2

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

Monitoring and Observation

• Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety 1, 2
• Monitor for signs of organ hypoperfusion: new chest pain, altered mental status, or acute kidney injury 1
• Avoid excessive BP falls that may precipitate renal, cerebral, or coronary ischemia 2

Common Pitfalls to Avoid

• Do NOT use IV medications for hypertensive urgency—these are reserved for true hypertensive emergencies with acute target organ damage 1, 2
• Do NOT use short-acting nifedipine due to uncontrolled BP drops and associated mortality 1, 2
• Do NOT treat asymptomatic severe hypertension as an emergency—most patients have urgency, not emergency, and aggressive IV treatment can cause harm 1
• Do NOT lower BP too rapidly—this can lead to cardiovascular complications including stroke 1, 2
• Many patients with acute pain or distress may have acutely elevated BP that will normalize when pain and distress are relieved, rather than requiring specific antihypertensive intervention 2

Follow-Up and Long-Term Management

• Address medication adherence issues, as many hypertensive urgencies result from non-compliance 1
• Schedule frequent follow-up visits (at least monthly) until target BP is reached 1
• Arrange appropriate outpatient follow-up to ensure continued BP control rather than hospital admission 2
• Patients with previous hypertensive urgency remain at increased cardiovascular and renal risk compared to hypertensive patients without such events 1