Hypertensive Urgency: Initial Treatment
For hypertensive urgency (severe BP elevation >180/120 mmHg WITHOUT acute organ damage), initiate oral antihypertensive medications and arrange outpatient follow-up within 2-4 weeks—hospital admission and IV therapy are NOT required. 1, 2
Critical First Step: Confirm This is Urgency, Not Emergency
Before treating, you must rapidly exclude acute target organ damage that would make this a hypertensive emergency requiring ICU admission 1, 2:
- Neurologic: Assess for altered mental status, severe headache with vomiting, visual disturbances, focal deficits, or seizures suggesting hypertensive encephalopathy or stroke 1, 2
- Cardiac: Check for chest pain (acute coronary syndrome), severe dyspnea (pulmonary edema), or signs of heart failure 1, 2
- Renal: Evaluate for acute kidney injury with urinalysis and creatinine 2
- Vascular: Ask about tearing chest/back pain (aortic dissection) 2
- Ophthalmologic: Perform fundoscopy looking for papilledema, hemorrhages, or exudates 2, 3
If ANY of these are present, this is a hypertensive emergency requiring immediate ICU admission and IV therapy—not oral management. 1, 2
Oral Medication Selection for Confirmed Urgency
For Non-Black Patients:
Start with low-dose ACE inhibitor (captopril 25 mg) or ARB, then add a dihydropyridine calcium channel blocker if needed 2, 4. Captopril can be initiated at 25 mg twice or three times daily, taken one hour before meals 4.
For Black Patients:
Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 2.
Alternative Oral Agents:
- Captopril: 25 mg orally, can repeat 2, 4
- Labetalol: Oral formulation 2, 3
- Clonidine: Effective for urgencies 2, 5
Blood Pressure Reduction Goals
Do NOT attempt to normalize BP acutely. 1, 2 The goal is controlled reduction over hours to days:
- Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) achieved within 3 months, not immediately 2
- Gradual reduction prevents cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation 1, 2
Critical Medications to AVOID
- Short-acting nifedipine: Causes unpredictable precipitous BP drops and reflex tachycardia 2, 6, 7, 8
- IV medications: Reserved only for hypertensive emergencies with organ damage 1, 2
- Hydralazine: Associated with significant adverse effects 7, 8
Follow-Up Requirements
- Arrange outpatient follow-up within 2-4 weeks to assess treatment response 2
- Many patients (up to one-third) with diastolic BP >95 mmHg normalize spontaneously before follow-up 2
- Screen for secondary hypertension causes if BP remains uncontrolled 1, 2
- Address medication non-compliance, the most common trigger for hypertensive crises 2
Common Clinical Pitfall
Many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition (pain, anxiety) is treated—avoid treating the BP number alone without confirming sustained severe hypertension. 1, 2 Recheck BP after addressing pain/distress before initiating antihypertensive therapy.