What is the recommended treatment for a patient with hypertensive urgency?

Hypertensive Urgency Treatment

For hypertensive urgency (BP >180/120 mmHg WITHOUT acute target organ damage), initiate oral antihypertensive therapy and arrange outpatient follow-up within 24-48 hours—IV medications and hospital admission are NOT indicated. 1, 2

Critical First Step: Distinguish Urgency from Emergency

Before treating, you must confirm the absence of acute target organ damage 1, 2:

• Neurologic: No altered mental status, seizures, visual disturbances, headache with vomiting, or stroke 1
• Cardiac: No chest pain, acute MI, pulmonary edema, or acute heart failure 1
• Vascular: No aortic dissection 1
• Renal: No acute kidney injury or thrombotic microangiopathy 1
• Ophthalmologic: No papilledema, retinal hemorrhages, or cotton wool spots 1

If ANY of these are present, this is a hypertensive emergency requiring ICU admission and IV therapy 1.

Blood Pressure Reduction Goals

Target a gradual reduction: decrease BP by no more than 25% within the first hour, then to 160/100 mmHg within 2-6 hours, and cautiously normalize over 24-48 hours 2. Avoid rapid or excessive BP lowering, which can precipitate cerebral, renal, or coronary ischemia 2.

Oral Medication Selection

For Non-Black Patients:

Start with one of the following 1:

• ACE inhibitor (e.g., captopril 25 mg orally) - particularly useful when high renin activity is suspected; contraindicated in pregnancy and bilateral renal artery stenosis 2
• ARB (low initial dose due to potential sensitivity) 2
• Beta-blocker (e.g., labetalol 200-400 mg orally) - avoid in reactive airway disease, COPD, heart block, bradycardia, or decompensated heart failure 2

If inadequate response, add a dihydropyridine calcium channel blocker (avoid short-acting nifedipine due to risk of uncontrolled BP drops) 2. Use extended-release formulations only 2.

For Black Patients:

Initiate therapy with either 2:

• Calcium channel blocker (extended-release formulation) alone or combined with an ARB
• Diuretic alone or combined with an ARB

Special Populations:

• Sympathomimetic-induced hypertension (cocaine, methamphetamine): Use benzodiazepines first; avoid beta-blockers as they may worsen hypertension through unopposed alpha-stimulation 1, 2
• Pain-related hypertension: Treat the underlying pain first, as BP often normalizes when pain resolves 2

Monitoring and Follow-up

• Observe the patient for at least 2 hours after initiating therapy to evaluate efficacy and safety 2
• Arrange follow-up within 24-48 hours (some sources recommend within 24 hours for patients not hospitalized) to adjust medications and ensure BP control 2, 3
• Target long-term BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients), achieving this within 3 months 1

Critical Pitfalls to Avoid

• Do NOT use IV medications for hypertensive urgency—these are reserved for true emergencies with target organ damage 2
• Do NOT use immediate-release nifedipine due to unpredictable, precipitous BP drops and reflex tachycardia 1, 2
• Do NOT rapidly normalize BP in the acute setting, as patients with chronic hypertension have altered autoregulation and cannot tolerate acute normalization 1
• Do NOT dismiss medication non-compliance as the underlying cause—address this directly as it is the most common trigger 1
• Do NOT ignore asymptomatic patients—up to one-third may normalize BP spontaneously, and aggressive treatment may cause harm 2

What Hypertensive Urgency Is NOT

Many patients presenting with acute pain, anxiety, or distress have transiently elevated BP that normalizes when the underlying condition is treated 1. These patients do not require specific antihypertensive intervention beyond addressing the precipitating cause 1.