What is the best treatment approach for a patient presenting with hypertensive urgency?

Hypertensive Urgency Management

For hypertensive urgency (BP >180/120 mmHg without acute target organ damage), initiate oral antihypertensive therapy and arrange outpatient follow-up within 2-4 weeks—hospital admission and IV medications are not indicated. 1, 2

Critical First Step: Distinguish Emergency from Urgency

The presence or absence of acute target organ damage determines your entire management approach:

• Hypertensive urgency = severe BP elevation WITHOUT acute organ damage 1, 2
• Hypertensive emergency = severe BP elevation WITH acute organ damage (requires ICU admission and IV therapy) 1, 2

Assess immediately for target organ damage: 2

• Neurologic: altered mental status, headache with vomiting, visual disturbances, seizures, focal deficits
• Cardiac: chest pain, acute MI, pulmonary edema, acute heart failure
• Vascular: aortic dissection (tearing chest/back pain)
• Renal: acute kidney injury, oliguria
• Ophthalmologic: bilateral retinal hemorrhages, cotton wool spots, papilledema (requires fundoscopy)

If ANY of these are present, this is a hypertensive emergency requiring immediate ICU transfer with IV therapy—not hypertensive urgency. 2

Management Algorithm for Confirmed Hypertensive Urgency

Blood Pressure Targets

Target BP reduction of no more than 25% within the first hour, then to 160/100 mmHg over 2-6 hours if stable, with cautious normalization over 24-48 hours. 3 Avoid excessive acute drops >70 mmHg systolic, as patients with chronic hypertension have altered autoregulation and rapid normalization can precipitate cerebral, renal, or coronary ischemia. 1, 2

Oral Medication Selection

For Non-Black Patients: 2

• Start low-dose ACE inhibitor (captopril 12.5-25 mg PO) or ARB (losartan 25-50 mg PO)
• Add dihydropyridine calcium channel blocker (amlodipine 5 mg PO or extended-release nifedipine 30 mg PO) if needed
• Add thiazide or thiazide-like diuretic as third-line agent

For Black Patients: 2

• Start ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic
• Add the missing component (diuretic or ARB/ACE inhibitor) as third-line

Critical medication considerations: 3

• Captopril: Start 12.5-25 mg PO, particularly useful when high renin activity suspected; contraindicated in pregnancy and bilateral renal artery stenosis 3, 4
• Extended-release nifedipine: 30-60 mg PO; never use immediate-release nifedipine due to unpredictable precipitous drops and reflex tachycardia 3
• Labetalol: 100-200 mg PO; contraindicated in reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 3

Monitoring and Observation

Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety. 3 Many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated—avoid treating the BP number alone without assessing for true emergency. 1, 2

Follow-Up

Arrange outpatient follow-up within 2-4 weeks to assess response to therapy, with target BP goal of <130/80 mmHg to <140/90 mmHg depending on patient characteristics. 2 Address medication non-compliance, which is the most common trigger for hypertensive urgencies. 2

Common Clinical Pitfalls to Avoid

Do not admit patients with hypertensive urgency to the hospital or use IV medications—this represents overtreatment and may cause harm through hypotension-related complications. 2, 3 Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up, and rapid BP lowering may be harmful. 2

Do not use immediate-release nifedipine—it causes unpredictable precipitous drops and reflex tachycardia. 3 Use extended-release formulations only.

Do not rapidly normalize BP in the acute phase—patients with chronic hypertension have altered cerebral and renal autoregulation and cannot tolerate acute normalization. 1, 2

Do not confuse transient BP elevations from pain/distress with true hypertensive urgency—treat the underlying cause first and reassess BP. 1, 2

Special Populations

Patients with renal failure (eGFR <30 mL/min/1.73m²): Use loop diuretics (furosemide) instead of thiazides; start ACE inhibitors/ARBs at very low doses with close monitoring due to unpredictable responses. 5

Patients with sympathomimetic use (cocaine, methamphetamine): Exercise caution with beta-blocker use; consider benzodiazepines first for BP control. 1, 3