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

Hypertensive Urgency Management

Critical First Distinction: Rule Out Hypertensive Emergency

Hypertensive urgency is defined as severely elevated blood pressure (typically >180/120 mmHg) WITHOUT acute target organ damage and should be managed with oral antihypertensive medications and outpatient follow-up—NOT hospital admission or IV therapy. 1, 2

The presence or absence of acute hypertension-mediated organ damage (HMOD) is the sole determining factor for management approach, not the absolute blood pressure number itself. 1, 2

Immediately Assess for Target Organ Damage

You must actively exclude acute HMOD through systematic evaluation before proceeding with outpatient management: 1, 3

Neurologic damage:

• Altered mental status, somnolence, lethargy (may precede seizures/coma in hypertensive encephalopathy) 1
• Headache with vomiting, visual disturbances, focal deficits 1, 3
• Acute stroke symptoms 1

Cardiac damage:

• Chest pain suggesting acute myocardial ischemia/infarction 1
• Acute pulmonary edema or heart failure 1

Vascular damage:

• Signs/symptoms of aortic dissection 1

Renal damage:

• Acute deterioration in renal function (check creatinine) 1
• Significant proteinuria on urinalysis 1

Ophthalmologic damage:

• Fundoscopy showing bilateral retinal hemorrhages, cotton wool spots, or papilledema (Grade III-IV retinopathy defining malignant hypertension) 1, 3

Laboratory screening:

• Complete blood count, lactate dehydrogenase, haptoglobin to assess for thrombotic microangiopathy 1, 3

If ANY of these are present, this is a hypertensive emergency requiring immediate ICU admission with IV therapy—NOT hypertensive urgency. 1, 3

---

Blood Pressure Reduction Strategy for Confirmed Hypertensive Urgency

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. 2, 3

The long-term target BP goal is <130/80 mmHg to <140/90 mmHg depending on patient age and frailty, achieved over weeks to months—NOT acutely. 2

Critical Pitfall to Avoid

Do NOT rapidly normalize blood pressure in the acute phase. Patients with chronic hypertension have altered cerebral and renal autoregulation and cannot tolerate acute normalization—this may cause cerebral, renal, or coronary ischemia. 1, 3 Excessive acute drops >70 mmHg systolic can precipitate these ischemic complications. 1

---

Oral Medication Selection

For Non-Black Patients:

Start with low-dose ACE inhibitor or ARB (e.g., captopril 25 mg PO three times daily). 2

• Add dihydropyridine calcium channel blocker if needed 2
• Titrate to full doses before adding third agent 2
• Add thiazide or thiazide-like diuretic as third-line 2

For Black Patients:

Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic. 2, 3

• Titrate to full doses 2
• Add the missing component (diuretic or ARB/ACEI) as third-line 2

Special Population Considerations:

Renal failure patients: Use loop diuretics instead of thiazides; start ACE inhibitors/ARBs at very low doses with close monitoring due to unpredictable responses. 2, 3

Suspected secondary hypertension: Screen for renovascular disease, pheochromocytoma, or primary aldosteronism after stabilization, as 20-40% of patients with malignant hypertension have identifiable secondary causes. 4, 2

---

Monitoring and Observation

Observe the patient for at least 2 hours after initiating or adjusting medication to evaluate BP lowering efficacy and safety. 2, 3

This observation period is essential to ensure the patient does not experience excessive BP drops or adverse medication effects before discharge. 2

---

Follow-Up Arrangement

Arrange outpatient follow-up within 2-4 weeks to assess response to therapy and titrate medications to goal BP. 2, 3

Up to one-third of patients with elevated blood pressure normalize before follow-up, and rapid blood pressure lowering may be harmful. 1 Ensuring close follow-up prevents both overtreatment and undertreatment. 2

---

What NOT to Do: Common Clinical Pitfalls

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. 3 Hospital admission is only indicated for hypertensive emergencies with acute target organ damage. 1, 3

Do NOT initiate treatment for asymptomatic hypertension in the emergency department when patients have follow-up arranged. Rapidly lowering blood pressure in asymptomatic patients may be harmful (Level B recommendation). 1

Do NOT use immediate-release nifedipine, hydralazine, or sodium nitroprusside for hypertensive urgency. These agents have unpredictable effects and are associated with significant toxicities. 1, 5

Do NOT confuse isolated subconjunctival hemorrhage with malignant hypertensive retinopathy. Subconjunctival hemorrhage is NOT acute target organ damage; malignant hypertension requires bilateral retinal hemorrhages, cotton wool spots, or papilledema. 1