Hypertensive Urgency Discharge Criteria
Patients with hypertensive urgency (BP >180/120 mmHg WITHOUT acute target organ damage) can be safely discharged from the emergency department after initiating or intensifying oral antihypertensive therapy and arranging close outpatient follow-up within 2-4 weeks. 1
Critical Distinction: Emergency vs. Urgency
The presence or absence of acute target organ damage—not the blood pressure number itself—determines whether a patient requires admission or can be discharged. 1, 2
Must Rule Out Target Organ Damage Before Discharge
Perform focused assessment for:
Neurologic damage: Altered mental status, headache with neurologic signs, visual disturbances, seizures, focal deficits, or signs of stroke/hemorrhage 1
Cardiac damage: Chest pain, acute MI, unstable angina, acute heart failure with pulmonary edema, or ECG changes suggesting ischemia 1
Renal damage: Acute kidney injury (elevated creatinine), hematuria, proteinuria, or signs of thrombotic microangiopathy (hemolysis, thrombocytopenia) 1, 3
Vascular damage: Signs of aortic dissection (tearing chest/back pain, pulse differentials, widened mediastinum) 1
Ophthalmologic damage: Fundoscopic exam showing flame-shaped hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 1
Discharge Criteria Checklist
Patient can be discharged if ALL of the following are met:
- No evidence of acute target organ damage on history, physical exam, and basic testing 1
- Patient is clinically stable without symptoms suggesting ongoing organ injury 1, 2
- Basic laboratory tests are reassuring: Normal or stable creatinine, no proteinuria/hematuria, no evidence of hemolysis or thrombocytopenia 3
- ECG shows no acute ischemic changes 3
- Patient can reliably take oral medications and has no contraindications 1
- Close outpatient follow-up can be arranged within 2-4 weeks 1
Discharge Management Protocol
Initiate or Intensify Oral Antihypertensive Therapy
For non-Black patients: Start low-dose ACE inhibitor or ARB, add dihydropyridine calcium channel blocker if needed, then add thiazide/thiazide-like diuretic as third-line 1
For Black patients: Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1
Target BP: <130/80 mmHg (or <140/90 mmHg in elderly/frail patients), to be achieved within 3 months 1
Discharge Instructions
- BP should be lowered gradually over 24-48 hours, not acutely in the ED 1
- Avoid rapid BP reduction as patients with chronic hypertension have altered autoregulation and acute normalization can cause cerebral, renal, or coronary ischemia 1
- Arrange follow-up within 2-4 weeks to assess response to therapy and adjust medications 1
- Emphasize medication adherence, as non-compliance is the most common trigger for hypertensive crises 1
Common Pitfalls to Avoid
Do not admit patients with hypertensive urgency to the hospital—they do not require ICU monitoring or IV medications 1
Do not use short-acting nifedipine for acute BP reduction due to unpredictable precipitous drops and reflex tachycardia 1, 3
Do not attempt to normalize BP acutely in the ED—up to one-third of patients with diastolic BP >95 mmHg normalize spontaneously before follow-up, and rapid lowering may cause harm 2
Do not discharge without arranging definite follow-up—many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated, but true hypertensive urgency requires ongoing management 2
Screen for secondary hypertension causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) after stabilization, as 20-40% of patients with severe hypertension have secondary causes 1, 3