What is the appropriate management for a patient presenting with hypertensive urgency?

Hypertensive Urgency Management

Definition and Critical Distinction

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 with IV medications or hospital admission. 1, 2

The presence or absence of acute target organ damage—not the absolute blood pressure number—is the sole determining factor that differentiates hypertensive urgency from hypertensive emergency. 1, 2

Immediate Assessment for Target Organ Damage

Before initiating treatment, you must actively exclude acute target organ damage through systematic evaluation: 1, 2

Neurologic Assessment

• Brief mental status examination looking for altered consciousness, confusion, or lethargy 1
• Assess for severe headache with vomiting, visual disturbances, or seizures (suggesting hypertensive encephalopathy) 1
• Check for focal neurologic deficits (suggesting stroke) 1

Cardiac Assessment

• Evaluate for chest pain suggesting acute coronary syndrome 1
• Assess for dyspnea or signs of acute pulmonary edema 1

Ophthalmologic Assessment

• Fundoscopy to identify bilateral retinal hemorrhages, cotton wool spots, or papilledema (Grade III-IV retinopathy indicating malignant hypertension) 1, 2
• Note: Isolated subconjunctival hemorrhage is NOT acute target organ damage 1

Renal Assessment

• Check for acute deterioration in renal function 1
• Laboratory screening including creatinine, urinalysis for proteinuria 1

Vascular Assessment

• Assess for symptoms suggesting aortic dissection (tearing chest/back pain) 1

Management Approach for Hypertensive Urgency

If no acute target organ damage is present, manage with oral medications and avoid rapid blood pressure reduction. 1, 2

Oral Medication Selection

For Non-Black Patients: 1

• Start low-dose ACE inhibitor (e.g., captopril 25 mg bid-tid) or ARB 1, 3
• Add dihydropyridine calcium channel blocker if needed 1
• Titrate to full doses before adding third agent 1
• Add thiazide or thiazide-like diuretic as third-line 1

For Black Patients: 1

• Start low-dose ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1
• Titrate to full doses 1
• Add the missing component (diuretic or ARB/ACE inhibitor) as third-line 1

Alternative oral agents with demonstrated efficacy: 2, 4, 5

• Captopril (oral) 2, 3, 4
• Labetalol (oral) 2, 4
• Nifedipine retard (NOT immediate-release) 2, 4

Blood Pressure Reduction Goals

• Reduce blood pressure gradually over 24-48 hours, NOT acutely 1
• Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) 1
• Achieve target within 3 months 1
• Avoid rapid blood pressure lowering—this may cause cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation 1, 2

Disposition and Follow-up

• Patients can be discharged even if BP remains >180/110 mmHg IF there is no evidence of acute target organ damage and oral antihypertensive therapy is initiated or adjusted 1
• Arrange outpatient follow-up within 2-4 weeks to assess response to therapy 1, 2
• Up to one-third of patients with elevated diastolic BP >95 mmHg normalize before follow-up 1

Critical Pitfalls to Avoid

• Do NOT admit patients with asymptomatic hypertension without evidence of acute target organ damage 1
• Do NOT use IV medications for hypertensive urgency—oral therapy is appropriate 1, 2
• Do NOT rapidly lower blood pressure in asymptomatic patients—this may be harmful through hypotension-related complications including acute kidney injury, cerebral ischemia, or coronary ischemia 1, 6
• Do NOT use immediate-release nifedipine due to unpredictable precipitous blood pressure drops and reflex tachycardia 1, 7, 8
• Do NOT confuse isolated findings like epistaxis or subconjunctival hemorrhage with true target organ damage 1, 2
• Do NOT assume absence of symptoms means absence of organ damage—active exclusion through focused examination is required 1

When to Refer to Emergency Department

Immediate ER referral is required if ANY of the following are present: 1

• Altered mental status, somnolence, lethargy, seizures, or focal neurologic deficits 1
• Severe headache with multiple episodes of vomiting 1
• Chest pain suggesting acute coronary syndrome 1
• Acute dyspnea or pulmonary edema 1
• Bilateral retinal hemorrhages, cotton wool spots, or papilledema on fundoscopy 1
• Acute deterioration in renal function 1
• Symptoms suggesting aortic dissection 1
• Eclampsia or severe preeclampsia in pregnancy 1

Special Considerations

• Screen for secondary hypertension causes after stabilization, as 20-40% of patients with malignant hypertension have identifiable causes including renal artery stenosis, pheochromocytoma, or primary aldosteronism 1
• Address medication non-adherence, the most common trigger for hypertensive crises 1
• Many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated—avoid treating the BP number alone without assessing for true hypertensive emergency 1