What qualifies as hypertensive urgency, formerly known as malignant hypertension or hypertensive emergency (HE) with severely elevated Blood Pressure (BP)?

From the Guidelines

Hypertensive urgency is defined as a severe elevation in blood pressure, typically with a systolic blood pressure above 180 mmHg and/or a diastolic blood pressure above 120 mmHg, without evidence of acute target organ damage, and requires prompt medical attention but not necessarily emergency hospitalization. This condition is characterized by the absence of acute or impending change in target organ damage or dysfunction, and patients often present with symptoms such as headache, shortness of breath, or anxiety, though some may be asymptomatic 1. The goal of treatment is to lower blood pressure gradually over 24-48 hours, rather than rapidly, to avoid complications from sudden drops in pressure.

Key Characteristics of Hypertensive Urgency

• Severe elevation in blood pressure, typically with a systolic blood pressure above 180 mmHg and/or a diastolic blood pressure above 120 mmHg
• No evidence of acute target organ damage
• Patients may present with symptoms such as headache, shortness of breath, or anxiety, though some may be asymptomatic
• Requires prompt medical attention but not necessarily emergency hospitalization

Treatment of Hypertensive Urgency

Commonly used medications include oral agents such as captopril (25 mg), labetalol (200-400 mg), amlodipine (5-10 mg), or clonidine (0.1-0.2 mg) 1. These medications should be followed by adjustments to the patient's regular antihypertensive regimen. It's essential to distinguish hypertensive urgency from hypertensive emergency, which involves target organ damage such as encephalopathy, stroke, acute heart failure, or kidney injury and requires immediate hospitalization with intravenous medications. The underlying pathophysiology involves increased systemic vascular resistance, often due to medication non-adherence, inadequate treatment, or secondary causes of hypertension such as renal disease or endocrine disorders. According to the most recent guidelines, patients with hypertensive urgency should be treated with oral BP-lowering medication or adaptation of their current BP-lowering medication, and rapid BP lowering is not recommended 1.

From the Research

Definition of Hypertensive Urgency

• Hypertensive urgency is defined as a severe elevation in blood pressure, higher than 180/120 mmHg, without evidence of new or worsening organ damage 2.
• It is characterized by a blood pressure elevation (diastolic > 120 mmHg) with the absence of acute target organ disease 3.

Management of Hypertensive Urgency

• The management of hypertensive urgency involves a gradual lowering of blood pressure over 24-48 hours with an oral medication 2.
• Oral antihypertensive agents such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine have been shown to be effective in managing hypertensive urgencies 4, 3.
• The choice of specific drug depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities 2.
• Aggressive blood pressure lowering should be avoided in hypertensive urgencies 2.

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 3.
• Hypertensive emergencies require immediate treatment with parenteral drugs and careful intraarterial blood pressure monitoring, whereas hypertensive urgencies can usually be managed with oral agents 3.