How to manage a patient with hypertensive urgency?

Management of Hypertensive Urgency

Hypertensive urgency should be managed with oral antihypertensive medications and outpatient follow-up within 2-4 weeks, without hospital admission or intravenous therapy. 1, 2

Definition and Critical Distinction

Hypertensive urgency is defined as severely elevated blood pressure (typically >180/120 mmHg) without evidence of acute target organ damage. 1, 2 The presence or absence of acute organ damage—not the absolute blood pressure number—is the sole determining factor that differentiates urgency from emergency. 1, 2

Do not admit patients with asymptomatic hypertension without evidence of acute target organ damage, as this represents hypertensive urgency, not emergency. 1

Initial Assessment

Before initiating treatment, you must systematically assess for acute target organ damage: 1, 2

Neurologic Assessment

• Altered mental status, somnolence, lethargy, headache with vomiting, visual disturbances, or seizures suggest hypertensive encephalopathy (emergency, not urgency) 1, 2
• Focal neurological deficits suggest stroke (emergency) 1, 2

Cardiac Assessment

• Chest pain suggesting acute myocardial ischemia or infarction (emergency) 1, 2
• Acute pulmonary edema or heart failure (emergency) 1, 2

Ophthalmologic Assessment

• Bilateral retinal hemorrhages, cotton wool spots, or papilledema indicate malignant hypertension (emergency) 1, 2
• Isolated subconjunctival hemorrhage is NOT acute target organ damage and does not require admission 1

Renal Assessment

• Acute deterioration in renal function (emergency) 1, 2

Vascular Assessment

• Symptoms suggesting aortic dissection (emergency) 1, 2

If any of these are present, the patient has a hypertensive emergency requiring ICU admission and IV therapy—not hypertensive urgency. 1, 2

Blood Pressure Confirmation

Confirm the blood pressure elevation with repeat measurement using proper technique before initiating treatment. 1 Up to one-third of patients with diastolic blood pressure >95 mmHg normalize before arranged follow-up. 1

Oral Medication Management

First-Line Oral Agents

For Non-Black Patients: 1

• 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: 1

• 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

Alternative Oral Agents

Captopril, labetalol, or nifedipine retard have been proposed, though limited data exist on optimal treatment. 1 In patients with renal failure, ACE inhibitors or ARBs should be started at very low doses due to unpredictable responses in the acute setting. 1

Blood Pressure Target

Target blood pressure <130/80 mmHg (or <140/90 mmHg in elderly/frail patients), achieving target within 3 months. 1

Critical Pitfalls to Avoid

Do not rapidly lower blood pressure in hypertensive urgency—this may cause harm through hypotension-related complications including cerebral, renal, or coronary ischemia. 1, 2 Patients with chronic hypertension have altered autoregulation and cannot tolerate acute normalization of blood pressure. 1, 2

Do not use IV medications for hypertensive urgency—oral therapy is appropriate and IV therapy may cause excessive drops leading to organ hypoperfusion. 1, 2

Do not use immediate-release nifedipine due to unpredictable precipitous blood pressure drops and reflex tachycardia. 1, 2

Do not admit to hospital or ICU unless acute target organ damage is identified. 1, 2

Do not treat the blood pressure number alone without assessing for true hypertensive emergency, as many patients presenting with acute pain or distress have transiently elevated blood pressure that normalizes when the underlying condition is treated. 1

Follow-Up and Long-Term Management

Arrange outpatient follow-up within 2-4 weeks to assess response to therapy. 1 Initiating treatment for asymptomatic hypertension in the emergency department is not necessary when patients have follow-up arranged. 1

Address medication non-adherence, the most common trigger for hypertensive crises. 2 After stabilization, screen for secondary hypertension causes, as 20-40% of patients with severe hypertension have identifiable causes including renal artery stenosis, pheochromocytoma, or primary aldosteronism. 1, 2

Patients who experience hypertensive urgency remain at increased cardiovascular and renal risk, requiring frequent follow-up (at least monthly) until target blood pressure is reached. 1, 2