Hypertensive Urgency Management
For hypertensive urgency (BP >180/120 mmHg WITHOUT acute organ damage), initiate oral antihypertensive therapy and arrange outpatient follow-up within 2-4 weeks—IV medications and hospital admission are NOT indicated. 1
Critical First Step: Exclude Hypertensive Emergency
Before treating as urgency, rapidly assess for acute target organ damage that would indicate emergency requiring ICU admission 1:
- Neurologic: Altered mental status, severe headache with vomiting, visual disturbances, seizures, focal deficits 2
- Cardiac: Chest pain, acute MI, pulmonary edema, acute heart failure 2
- Vascular: Aortic dissection symptoms 2
- Renal: Acute kidney injury, oliguria 2
- Ophthalmologic: Fundoscopy for papilledema, hemorrhages, exudates 3
If ANY target organ damage is present, this is a hypertensive emergency requiring immediate ICU admission and IV therapy. 3
Oral Medication Selection for Hypertensive Urgency
For Non-Black Patients:
- Start with low-dose ACE inhibitor (captopril 25 mg) or ARB 1
- Add dihydropyridine calcium channel blocker if needed 1
- Add thiazide/thiazide-like diuretic as third-line agent 1
For Black Patients:
- Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 1
- Add the missing component (diuretic or ARB/ACEI) as third-line 1
Captopril dosing for hypertensive urgency: Initial 25 mg orally, may increase to 50 mg two to three times daily if BP not controlled after 1-2 weeks 4
Blood Pressure Reduction Goals
Reduce BP gradually over hours to days—NOT immediately 1:
- Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) 1
- Achieve target within 3 months 1
- Avoid rapid reduction: Patients with chronic hypertension have altered autoregulation and acute normalization can cause cerebral, renal, or coronary ischemia 1
The rate of BP rise is more important than the absolute value—patients with chronic hypertension often tolerate higher pressures than previously normotensive individuals 2
Follow-Up Requirements
- Arrange outpatient follow-up within 2-4 weeks to assess treatment response 1
- Many patients with diastolic BP >95 mmHg normalize spontaneously before follow-up 1
- Screen for secondary hypertension causes if BP remains uncontrolled (found in 20-40% of malignant hypertension cases) 3, 1
- Address medication non-compliance, the most common trigger for hypertensive crises 1
Critical Pitfalls to Avoid
Do NOT use immediate-release nifedipine for hypertensive urgency due to unpredictable precipitous BP drops and reflex tachycardia 5, 6
Do NOT admit to hospital or use IV medications unless acute organ damage is present—hypertensive urgency can be managed entirely as outpatient 1, 6
Do NOT reduce BP to normal acutely—excessive drops >70 mmHg systolic can precipitate ischemic complications in patients with chronic hypertension 3, 1
Do NOT treat the BP number alone—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 2