Blood Pressure Goal in Hypertensive Urgency
In hypertensive urgency, blood pressure should be gradually reduced over 24-48 hours using oral antihypertensive medications, without specific numeric targets for the acute phase, as the goal is to avoid precipitous drops that could cause end-organ ischemia. 1
Defining Hypertensive Urgency
Hypertensive urgency is characterized by severely elevated blood pressure (>180/120 mmHg) without evidence of acute target organ damage. 1 This is the critical distinction from hypertensive emergency—the absence of acute organ dysfunction means there is no need for immediate, aggressive blood pressure reduction. 2, 3
Management Approach
The fundamental principle is gradual blood pressure reduction over 24-48 hours, not immediate normalization. 1, 4
Key Management Steps:
- Reinstitute or intensify oral antihypertensive therapy rather than using parenteral agents. 1
- Arrange outpatient follow-up within 2-4 weeks to assess response to therapy. 3
- Avoid emergency department referral or hospitalization in most cases, as these patients are stable without acute organ damage. 1, 3
- Target long-term blood pressure goals of <130/80 mmHg to <140/90 mmHg depending on patient characteristics, but achieve this gradually over weeks to months, not acutely. 3
Critical Pitfalls to Avoid
Do not aggressively lower blood pressure in the acute setting. 3, 4 Rapid blood pressure reduction in hypertensive urgency can precipitate cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation. 1, 2
Avoid sublingual nifedipine due to unpredictable and potentially dangerous blood pressure drops. 3
Do not treat the blood pressure number alone—up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up without intervention. 2
Medication Selection
For oral therapy initiation or intensification:
- Non-Black patients: Start with low-dose ACE inhibitor or ARB, add dihydropyridine calcium channel blocker if needed, then thiazide diuretic as third-line. 2
- Black patients: Start with ARB plus calcium channel blocker OR calcium channel blocker plus thiazide diuretic. 2
Distinguishing from Hypertensive Emergency
The presence or absence of target organ damage—not the absolute blood pressure number—determines management. 2, 3 Signs of target organ damage requiring emergency treatment include:
- Neurologic symptoms (altered mental status, seizures, stroke) 1, 2
- Cardiac complications (acute MI, pulmonary edema, unstable angina) 1, 3
- Aortic dissection 3
- Acute kidney injury 2
- Advanced retinopathy with papilledema 3
If any of these are present, the patient has a hypertensive emergency requiring ICU admission and IV therapy, not a hypertensive urgency. 1, 3