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

Hypertensive Urgency Management

For hypertensive urgency (BP >180/120 mmHg WITHOUT acute target organ damage), initiate oral antihypertensive therapy and arrange outpatient follow-up within 2-4 weeks—do NOT admit to the hospital or use IV medications. 1

Critical First Step: Exclude Hypertensive Emergency

Before treating as urgency, you must rapidly exclude acute target organ damage that would indicate a hypertensive emergency requiring ICU admission 2, 1:

• Neurologic assessment: Check for altered mental status, headache with vomiting, visual disturbances, seizures, or focal deficits 2, 1
• Cardiac evaluation: Assess for chest pain suggesting acute myocardial ischemia, acute heart failure, or pulmonary edema 2
• Fundoscopic examination: Look specifically for bilateral retinal hemorrhages, cotton wool spots, or papilledema (Grade III-IV retinopathy)—isolated subconjunctival hemorrhage does NOT qualify as target organ damage 2, 1
• Renal function: Check for acute kidney injury with creatinine elevation, proteinuria, or abnormal urine sediment 2
• Laboratory screening: Obtain CBC, LDH, haptoglobin to exclude thrombotic microangiopathy 2, 1

The presence of ANY acute target organ damage converts this to a hypertensive emergency requiring immediate ICU admission and IV therapy 2, 1.

Oral Medication Selection

For Non-Black Patients 1:

• Start with low-dose ACE inhibitor (captopril 25 mg) or ARB 1
• Add dihydropyridine calcium channel blocker if needed after titrating ACE inhibitor/ARB to full dose 1
• Add thiazide or thiazide-like diuretic as third-line agent 1

For Black Patients 1:

• Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide diuretic 1
• Add the missing component (diuretic or ARB/ACEI) as third-line 1

Captopril Dosing (FDA-Approved) 3:

• Initial dose: 25 mg three times daily (taken one hour before meals) 3
• For severe hypertension (accelerated or malignant), may start at 25 mg bid or tid under close supervision 3
• Titrate upward if needed after 1-2 weeks to 50 mg tid, then up to 100-150 mg tid if necessary 3
• Maximum daily dose: 450 mg 3

Blood Pressure Reduction Goals

Reduce BP gradually over hours to days—NOT acutely 2, 1. Rapid BP lowering in hypertensive urgency may cause cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation 2, 1.

• Target BP: <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) 1
• Timeframe: Achieve target within 3 months 1
• Acceptable to discharge with BP >180/110 mmHg if no acute target organ damage and oral therapy initiated 2

Follow-Up Requirements

• Schedule outpatient follow-up within 2-4 weeks to assess treatment response 1
• Screen for secondary hypertension if BP remains uncontrolled (found in 20-40% of malignant hypertension cases) 1
• Address medication non-adherence, the most common trigger for hypertensive crises 1

Critical Pitfalls to Avoid

• Do NOT admit patients with asymptomatic hypertension without evidence of acute target organ damage 2
• Do NOT use IV medications for hypertensive urgency—oral therapy is appropriate 2
• Do NOT rapidly lower BP in asymptomatic patients, as up to one-third normalize spontaneously before follow-up and rapid lowering may be harmful 2, 1
• Do NOT confuse subconjunctival hemorrhage with malignant hypertensive retinopathy—the latter requires bilateral retinal hemorrhages, cotton wool spots, or papilledema 2
• Do NOT treat the BP number alone without assessing for true hypertensive emergency, as many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 2