What is the management of hypertensive urgency?

Management of Hypertensive Urgency

Definition and Diagnosis

Hypertensive urgency is defined as severe blood pressure elevation (>180/120 mmHg) without acute target organ damage and should be managed with oral antihypertensive medications in the outpatient setting. 1, 2

• Confirm the diagnosis with repeated blood pressure measurements in both arms to verify the elevation 1
• Distinguish from hypertensive emergency by systematically ruling out acute organ damage through:
  • Physical examination focusing on neurological status (altered mental status, headache with vomiting, visual disturbances, seizures suggest emergency) 1
  • Fundoscopic examination (retinal hemorrhages, cotton wool spots, or papilledema indicate malignant hypertension requiring emergency treatment) 1
  • Basic laboratory tests including renal function panel to exclude acute renal failure 1
  • Electrocardiogram to assess for acute cardiac involvement 1
  • Complete blood count to help exclude thrombotic microangiopathy 1

Treatment Approach

Gradual blood pressure reduction over 24-48 hours using oral medications is the cornerstone of management, with a target of reducing blood pressure to safer levels (generally <160/100 mmHg) without causing hypotension. 1, 2

Blood Pressure Reduction Strategy

• Reduce systolic blood pressure by no more than 25% within the first hour, then cautiously reduce to 160/100 mmHg within 2-6 hours 2
• Avoid rapid reduction to "normal" levels acutely, as patients with chronic hypertension have altered cerebrovascular autoregulation 1
• Excessive acute drops can precipitate cerebral, renal, or coronary ischemia 1, 2

Medication Selection

First-line oral agents include captopril, labetalol, and extended-release nifedipine, with selection based on patient comorbidities and current medications. 1

Specific Medication Considerations:

• Captopril: Particularly useful in hypertensive urgencies associated with high plasma renin activity; contraindicated in pregnancy and bilateral renal artery stenosis 2
• Labetalol: Contraindicated in reactive airways disease, COPD, second- or third-degree heart block, bradycardia, and decompensated heart failure 2
• Extended-release nifedipine: Preferred formulation; avoid short-acting immediate-release nifedipine due to unpredictable rapid BP falls that can cause cardiovascular complications 1, 2

Special Populations:

• For Black patients: Initial treatment should include a diuretic or calcium channel blocker, either alone or with a RAS blocker 2
• For sympathomimetic-induced hypertension (cocaine, methamphetamine): Benzodiazepines are first-line treatment; beta-blockers should be avoided as they may worsen coronary vasoconstriction 1, 2
• Use ACE inhibitors, ARBs, or beta-blockers with low initial doses due to potential sensitivity 2

Observation and Monitoring

• Observe the patient for at least 2 hours after medication administration to evaluate efficacy and safety 1, 2
• Hospital admission is generally not required unless there are concerning features or poor follow-up 1
• Intravenous medications should be avoided in hypertensive urgency and are reserved for true hypertensive emergencies 2

Follow-up and Long-term Management

Close follow-up within one week is essential to ensure adequate blood pressure control. 1

• Screen for secondary causes of hypertension 1
• Address medication adherence issues, which are often the underlying cause of hypertensive urgency 2
• Focus on improving medication compliance and addressing modifiable risk factors 1
• Patients with a history of hypertensive urgency remain at increased risk for cardiovascular and renal disease 1

Critical Pitfalls to Avoid

• Do not use intravenous medications - these are reserved for hypertensive emergencies with acute organ damage 2
• Do not use short-acting immediate-release nifedipine - unpredictable rapid BP falls can cause cardiovascular complications 1, 2
• Do not rapidly lower BP to "normal" levels - this can cause ischemic complications in patients with chronic hypertension who have altered cerebrovascular autoregulation 1
• Do not use beta-blockers in cocaine-induced hypertension - they may worsen coronary vasoconstriction 1
• Do not overlook pain or distress - many patients with acute pain or distress may have acutely elevated blood pressure that will normalize when pain and distress are relieved, rather than requiring specific antihypertensive intervention 2