What is the management of hypertensive urgency (high blood pressure emergency)?

From the Guidelines

Hypertensive urgency requires prompt but not immediate treatment to lower blood pressure safely over 24-48 hours. For patients with hypertensive urgency (systolic BP ≥180 mmHg or diastolic BP ≥110 mmHg without evidence of end-organ damage), oral medications are preferred, as stated in the 2020 international society of hypertension global hypertension practice guidelines 1. The goal is to reduce blood pressure by no more than 25% within the first few hours, then gradually to normal levels over subsequent days, to avoid rapid blood pressure reduction that can lead to organ hypoperfusion.

Key Considerations

• Start with short-acting oral agents like captopril 25 mg, labetalol 200-400 mg, or amlodipine 10 mg.
• Patients should be monitored closely with follow-up within 24-72 hours.
• After initial control, transition to long-term antihypertensive therapy based on comorbidities, typically including a combination of medications like ACE inhibitors, calcium channel blockers, or diuretics, as recommended by the 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
• Lifestyle modifications including sodium restriction, weight loss, regular exercise, and limiting alcohol consumption should be emphasized.

Differentiation from Hypertensive Emergency

Hypertensive urgency differs from hypertensive emergency, which involves end-organ damage and requires immediate IV therapy in an intensive care setting, as outlined in the esc council on hypertension position document on the management of hypertensive emergencies 1. The 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline also highlights the importance of distinguishing between hypertensive urgency and emergency, with the latter having a significantly higher 1-year death rate if left untreated 1.

Diagnostic Approach

When evaluating patients with hypertensive urgency, it is essential to rule out end-organ damage through diagnostic tests such as fundoscopy, ECG, and additional investigations as indicated by the clinical presentation, such as troponins for chest pain or CT/MRI brain for cerebral hemorrhage/stroke, as suggested in the 2020 international society of hypertension global hypertension practice guidelines 1. Secondary causes of hypertension should also be considered, with appropriate diagnostic workup to confirm or exclude secondary forms, as they can be found in 20%–40% of patients presenting with malignant hypertension 1.

From the FDA Drug Label

Hypertension - Initiation of therapy requires consideration of recent antihypertensive drug treatment, the extent of blood pressure elevation, salt restriction, and other clinical circumstances For patients with severe hypertension (e.g., accelerated or malignant hypertension), when temporary discontinuation of current antihypertensive therapy is not practical or desirable, or when prompt titration to more normotensive blood pressure levels is indicated, diuretic should be continued but other current antihypertensive medication stopped and captopril dosage promptly initiated at 25 mg bid or tid, under close medical supervision

The management of hypertensive urgency may involve the use of captopril or other antihypertensive agents.

• Captopril can be initiated at a dose of 25 mg bid or tid, with close medical supervision, especially in patients with severe hypertension.
• The dose of captopril may be increased every 24 hours or less under continuous medical supervision until a satisfactory blood pressure response is obtained or the maximum dose of captopril is reached 2.
• Labetalol may also be used in the management of hypertension, alone or in combination with other antihypertensive agents 3.

From the Research

Definition and Classification of Hypertensive Urgency

• Hypertensive urgency is characterized by an acute and critical increase in blood pressure without signs or symptoms of acute hypertensive target organ damage 4.
• It is defined as a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease 5.

Treatment of Hypertensive Urgency

• Hypertensive urgencies can usually be managed with oral agents, such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 5.
• Oral antihypertensive therapy is usually sufficient, and hospitalization is not required 4.
• Blood pressure should be lowered within 24 to 48 hours to avoid hypertensive target organ damage 4.
• Clonidine, labetalol, and nifedipine are effective agents for the treatment of hypertensive urgencies, with clonidine and labetalol having maximal blood pressure lowering effects at 2-4 hours, and nifedipine having a rapid onset of action within 0.5-1 hour 6, 7.

Comparison with Hypertensive Emergency

• Hypertensive emergency is a condition in which there is elevation of both systolic and diastolic blood pressure with the presence of acute target organ disease 5.
• Hypertensive emergencies require immediate lowering of blood pressure (about 25% within one to two hours) in an intensive care setting, whereas hypertensive urgencies can be managed with oral antihypertensive agents over a period of 24-48 hours 4, 8.