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

Hypertensive Urgency Management

Immediate Assessment: Rule Out Hypertensive Emergency

The critical first step is determining whether acute target organ damage is present—this alone differentiates hypertensive urgency from emergency, not the blood pressure number itself. 1

Confirm Blood Pressure Elevation

• Repeat measurement using proper technique to confirm BP >180/120 mmHg 2
• Single elevated reading may reflect acute pain, anxiety, or measurement error 1

Screen for Acute Target Organ Damage (requires immediate ER transfer if present)

• Neurologic: Altered mental status, somnolence, headache with vomiting, visual disturbances, seizures, focal deficits 1, 3
• Cardiac: Chest pain, acute pulmonary edema, dyspnea at rest 1, 3
• Vascular: Symptoms suggesting aortic dissection (tearing chest/back pain) 1, 3
• Renal: Acute oliguria or signs of acute kidney injury 1, 3
• Ophthalmologic: Perform fundoscopy looking for bilateral retinal hemorrhages, cotton wool spots, or papilledema (malignant hypertension) 1, 3

Obtain Basic Laboratory Assessment

• Creatinine, electrolytes (sodium, potassium), urinalysis for protein and sediment 1, 2
• ECG to assess for left ventricular hypertrophy or ischemia 3
• These help identify subclinical organ damage and guide medication selection 1

---

Oral Medication Selection for Hypertensive Urgency

If no acute target organ damage is present, initiate oral antihypertensive therapy—IV medications and hospitalization are not indicated and may cause harm. 1, 2

First-Line Oral Agents

For Non-Black Patients:

• Start captopril 25 mg PO three times daily as first-line 1
• Alternative: Extended-release nifedipine (never short-acting) or labetalol 2
• If inadequate response after 1-2 weeks, increase captopril to 50 mg three times daily 4
• Add thiazide diuretic (hydrochlorothiazide 25 mg daily) if BP remains uncontrolled 1, 4

For Black Patients:

• Start ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 1
• This combination addresses the lower renin profile typical in Black patients 1

Critical Medication Considerations

Captopril Dosing Nuances:

• Start at 6.25-12.5 mg in volume-depleted patients to avoid precipitous BP drops 2
• Standard starting dose is 25 mg three times daily, taken one hour before meals 4
• Maximum dose 150 mg three times daily (450 mg total daily) 4

Agents to AVOID:

• Never use short-acting (immediate-release) nifedipine—associated with unpredictable precipitous BP drops, stroke, and death 2, 5
• Avoid IV medications unless organ damage develops 2
• Do not use hydralazine as first-line due to unpredictable response 5

---

Blood Pressure Reduction Targets

Reduce BP by no more than 25% within the first hour, then aim for <160/100-110 mmHg over 2-6 hours, with gradual normalization over 24-48 hours. 1, 2

Why Gradual Reduction Matters

• Patients with chronic hypertension have altered cerebral, renal, and coronary autoregulation 1, 3
• Excessive acute drops (>70 mmHg systolic) precipitate end-organ ischemia 1, 3, 2
• Long-term goal is <130/80 mmHg to <140/90 mmHg depending on age and frailty, achieved over weeks to months 1

---

Monitoring and Observation

Observe the patient for at least 2 hours after initiating oral medication to evaluate BP-lowering efficacy and safety. 1, 2

• Monitor for excessive BP drops that could cause cerebral, renal, or coronary ischemia 1, 2
• Reassess for development of symptoms suggesting organ damage 2
• Most patients do not require hospitalization and can be discharged with close outpatient follow-up 2

---

Disposition and Follow-Up

Arrange outpatient follow-up within 24 hours to 2-4 weeks to assess response and titrate medications. 1, 2

• Schedule at least monthly follow-up until target BP is achieved 1, 2
• Screen for secondary hypertension causes (found in 20-40% of malignant hypertension cases): renovascular disease, pheochromocytoma, primary aldosteronism 1, 2
• Address medication non-adherence, the most common trigger for hypertensive crises 3

---

Special Populations

Patients with Renal Failure

• Use loop diuretics instead of thiazides 1
• Start ACE inhibitors/ARBs at very low doses (captopril 6.25 mg) with close monitoring due to unpredictable responses 1, 2
• Volume depletion from pressure natriuresis may occur—IV saline may be needed 3

Suspected Secondary Hypertension

• Screen after stabilization for renovascular disease, pheochromocytoma, or primary aldosteronism 1, 2
• Consider in patients with resistant hypertension or young age of onset 1

---

Critical Pitfalls to Avoid

• Do not hospitalize or use IV medications unless acute organ damage develops 1, 2
• Do not rapidly lower BP—up to one-third of patients normalize spontaneously, and aggressive lowering may cause harm 2, 6
• Do not treat transient BP elevations from acute pain or distress without confirming sustained elevation after addressing the underlying condition 3, 2
• Do not use short-acting nifedipine—this is associated with stroke and death 2, 5
• Do not apply inpatient aggressive BP targets—evidence for aggressive inpatient BP lowering is limited and may cause hypotension-related complications 3