What is the latest guideline for managing a patient with hypertensive urgency and a blood pressure above 180/120 mmHg, particularly those with a history of cardiovascular disease or heart failure?

Management of Hypertensive Urgency

Critical Distinction: Urgency vs. Emergency

Hypertensive urgency (BP >180/120 mmHg WITHOUT acute target organ damage) should be managed with oral antihypertensive medications and outpatient follow-up within 2-4 weeks—NOT with IV medications or hospital admission. 1, 2, 3

The presence or absence of acute target organ damage is the sole determining factor for emergency management, not the blood pressure number itself. 2

Immediate Assessment Required

Confirm Blood Pressure Elevation

• Repeat measurement using proper technique to confirm BP >180/120 mmHg 2
• Assess rate of BP rise, which may be more important than absolute value 1, 2

Screen for Target Organ Damage (determines if true emergency)

Neurologic damage: 1, 2

• Altered mental status, somnolence, or lethargy
• Headache with vomiting
• Visual disturbances or seizures
• Focal neurologic deficits

Cardiac damage: 1, 2

• Chest pain suggesting acute myocardial ischemia
• Acute pulmonary edema
• Acute heart failure symptoms

Vascular damage: 1, 2

• Signs of aortic dissection (tearing chest/back pain)

Renal damage: 1, 2

• Acute deterioration in renal function
• Oliguria or signs of acute kidney injury

Ophthalmologic damage: 1, 2

• Fundoscopy showing bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension)
• Note: Isolated subconjunctival hemorrhage is NOT acute target organ damage 2

Obstetric: 2

• Eclampsia or severe preeclampsia symptoms

Management Algorithm for Hypertensive Urgency

If NO Target Organ Damage Present (Hypertensive Urgency):

Oral Antihypertensive Therapy 1, 2, 3

For Non-Black Patients: 2

• Start low-dose ACE inhibitor or ARB
• Add dihydropyridine calcium channel blocker if needed
• Titrate to full doses before adding third agent
• Add thiazide or thiazide-like diuretic as third-line

For Black Patients: 2

• Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic
• Titrate to full doses
• Add the missing component (diuretic or ARB/ACEI) as third-line

Blood Pressure Targets: 2, 3

• Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients)
• Achieve target within 3 months
• Do NOT rapidly lower BP—this may cause harm through hypotension-related complications 2, 3

Follow-up: 2, 3

• Arrange outpatient follow-up within 2-4 weeks
• No hospital admission or IV medications required

Special Populations with Cardiovascular Disease or Heart Failure:

For patients with history of heart failure (especially EF <40%): 2

• Prioritize ACE inhibitor or ARB
• Add beta-blocker
• Add aldosterone receptor antagonist if EF <40%
• Use thiazide or thiazide-type diuretics for chronic BP control

For patients with cardiovascular disease: 1, 3

• Target systolic BP 120-129 mmHg to reduce cardiovascular risk
• Consider fixed-dose single-pill combination treatment for improved adherence
• Ensure combination includes RAS blocker, calcium channel blocker, and diuretic

Critical Pitfalls to Avoid

Do NOT: 1, 2, 3

• Admit patients with asymptomatic hypertension without evidence of acute target organ damage
• Use IV medications for hypertensive urgency—oral therapy is appropriate
• Use immediate-release nifedipine due to unpredictable precipitous drops and reflex tachycardia
• Rapidly lower BP in hypertensive urgency—up to one-third of patients normalize before follow-up, and rapid lowering may be harmful
• Confuse subconjunctival hemorrhage with malignant hypertensive retinopathy
• Treat the BP number alone without assessing for true hypertensive emergency

Important clinical context: 2, 3

• Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals due to altered autoregulation
• Many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated
• Initiating treatment for asymptomatic hypertension in the emergency department is not necessary when patients have follow-up (Level B recommendation)

When to Send to Emergency Department

Immediate ER referral is required ONLY if: 2

• BP ≥180/120 mmHg AND evidence of acute target organ damage
• Phaeochromocytoma crisis (sudden severe hypertension with palpitations, diaphoresis, headache)
• Drug-induced hypertensive emergency with acute organ damage
• Pregnancy-related severely elevated BP with symptoms suggesting preeclampsia/eclampsia