What is the initial approach to managing hypertensive urgency in an adult patient in the ER setting?

Initial Management of Hypertensive Urgency in the ER

For asymptomatic patients with severe hypertension (>180/120 mmHg) without acute target organ damage, do NOT initiate treatment in the ED—arrange outpatient follow-up within 24-48 hours for gradual oral antihypertensive therapy. 1, 2

Critical First Step: Differentiate Emergency from Urgency

Hypertensive urgency is defined as BP >180/120 mmHg WITHOUT acute target organ damage, while hypertensive emergency includes acute organ damage requiring immediate ICU admission. 3, 1

Rapidly Assess for Target Organ Damage

Perform focused examination within minutes looking for: 1, 2

• Neurologic: Altered mental status, confusion, severe headache, visual changes, seizures, focal deficits
• Cardiac: Chest pain, acute dyspnea, signs of acute MI or heart failure
• Vascular: Severe tearing chest/back pain (aortic dissection)
• Renal: Oliguria, acute renal failure
• Ophthalmologic: Fundoscopy for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension)

Key distinction: Subconjunctival hemorrhage alone is NOT target organ damage. 1 The rate of BP rise matters more than the absolute value—patients with chronic hypertension tolerate higher pressures than previously normotensive individuals. 3, 1

Management Algorithm for True Hypertensive Urgency

What NOT to Do

• Do NOT admit to hospital 1, 2
• Do NOT use IV medications 1, 2
• Do NOT rapidly lower BP in the ED—this is unnecessary and potentially harmful, causing renal, cerebral, or coronary ischemia 3, 1, 2
• Do NOT use short-acting nifedipine—risk of uncontrolled precipitous BP drops 1, 2

Up to one-third of patients with diastolic BP >95 mmHg normalize spontaneously before follow-up. 1, 2

Appropriate Management Steps

1. Confirm BP elevation with repeat measurement using proper technique 1, 2

2. Reinstitute or intensify oral antihypertensive therapy: 3, 1

   • For non-Black patients: Start low-dose ACE inhibitor or ARB, add dihydropyridine calcium channel blocker if needed, then thiazide diuretic as third-line 1
   • For Black patients: Start ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 1
   • Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 1

3. Arrange urgent outpatient follow-up within 24-48 hours with primary physician for gradual BP reduction over 24-48 hours 1, 2, 4, 5

4. Treat anxiety if applicable 3

If Target Organ Damage IS Present (Hypertensive Emergency)

This becomes a different clinical scenario requiring: 3, 1

• Immediate ICU admission (Class I recommendation, Level B-NR)

• Continuous arterial line BP monitoring

• Parenteral IV antihypertensive therapy:

  • First-line: Nicardipine IV (initial 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes to max 15 mg/hr) 3, 1
  • Alternative: Labetalol IV (0.25-0.5 mg/kg bolus or 2-4 mg/min infusion) 1

• BP reduction targets: 3, 1

  • Reduce mean arterial pressure by 20-25% within first hour
  • Then to 160/100 mmHg over next 2-6 hours if stable
  • Cautiously normalize over 24-48 hours
  • Exception: For aortic dissection, reduce SBP to <120 mmHg within first hour 3

Common Pitfalls to Avoid

• 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 1
• Do NOT confuse urgency with emergency—treating urgency as emergency leads to unnecessary hospitalization and potential harm from overly aggressive treatment 2
• Do NOT use immediate-release nifedipine, hydralazine, or sodium nitroprusside in the outpatient urgency setting 1
• Avoid excessive acute BP drops >70 mmHg systolic—this precipitates cerebral, renal, or coronary ischemia 3, 1

Laboratory Evaluation (If Uncertainty Exists)

If uncertain whether target organ damage is present, obtain: 1

• Complete blood count (hemoglobin, platelets)
• Basic metabolic panel (creatinine, sodium, potassium)
• Urinalysis for protein and sediment
• ECG
• Troponins if chest pain present

The focus in true hypertensive urgency is gradual BP reduction over days, not hours, with oral medications and close outpatient follow-up. 1, 2, 4, 6