Hypertensive Urgency Definition
Hypertensive urgency is defined as severely elevated blood pressure (>180/120 mmHg) WITHOUT evidence of acute target organ damage. 1, 2, 3
Key Distinguishing Features
The presence or absence of acute target organ damage is the sole deciding factor that distinguishes hypertensive urgency from hypertensive emergency. 2 This is the most critical distinction in clinical practice, as it completely changes management approach and urgency of intervention.
Blood Pressure Threshold
- Systolic BP >180 mmHg OR diastolic BP >120 mmHg 1, 3
- However, the absolute BP number is less important than the absence of organ damage 1
- Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals 1
Absence of Target Organ Damage
Patients with hypertensive urgency are otherwise stable with no acute or impending change in target organ function. 3 This means:
- No neurologic damage: No hypertensive encephalopathy, acute stroke, or intracranial hemorrhage 2
- No cardiac damage: No acute myocardial infarction, unstable angina, or acute heart failure with pulmonary edema 2
- No renal damage: No acute kidney injury or thrombotic microangiopathy 1
- No vascular damage: No aortic dissection 2
- No ophthalmologic damage: No acute retinal hemorrhages, papilledema, or malignant hypertension findings 1
Clinical Presentation
Patients may have non-specific symptoms including:
- Palpitations, headache, malaise, and general feeling of illness 4
- These symptoms alone do NOT constitute target organ damage 4
Management Implications
Hypertensive urgency can be managed with oral medications and outpatient follow-up—it does NOT require hospital admission or IV medications. 2, 3 This is fundamentally different from hypertensive emergency:
- BP should be reduced gradually over 24-48 hours, NOT within minutes 4
- Oral antihypertensives are appropriate 3, 5
- Outpatient follow-up within 2-4 weeks is recommended 2, 3
- Target BP <130/80 mmHg to <140/90 mmHg depending on patient characteristics 1
Critical Clinical Pitfall
Do not treat the blood pressure number alone without systematically assessing for true target organ damage. 2 Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and rapid BP lowering may actually be harmful in the absence of organ damage. 1 Many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated. 1