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
The presence or absence of acute target organ damage is the sole determining factor for management approach, not the absolute blood pressure number itself. 1 The rate of blood pressure rise may be more important than the absolute level, with patients having chronic hypertension often tolerating higher pressures than previously normotensive individuals. 1
Immediate Assessment for Target Organ Damage
Before initiating treatment, you must actively exclude acute hypertension-mediated organ damage through systematic evaluation: 1
Neurologic Assessment
- Brief mental status examination for altered consciousness, confusion, or lethargy 1
- Assess for headache with vomiting, visual disturbances, or seizures (suggesting hypertensive encephalopathy) 1
- Evaluate for focal neurologic deficits or unsteadiness (may indicate stroke or posterior reversible encephalopathy syndrome) 1, 2
- If unsteadiness is present, MRI brain imaging is recommended as this neurological symptom significantly increases likelihood of intracranial pathology 2
Cardiac Assessment
- Evaluate for chest pain suggesting acute coronary syndrome 1
- Assess for dyspnea or signs of acute pulmonary edema 1
- Obtain ECG to assess for ischemia or left ventricular hypertrophy 1
Ophthalmologic Assessment
- Fundoscopy is essential—look specifically for bilateral retinal hemorrhages, cotton wool spots, or papilledema (Grade III-IV retinopathy) 1
- Isolated subconjunctival hemorrhage is NOT acute target organ damage 1
Renal Assessment
- Check for acute deterioration in renal function 1
- Obtain urinalysis for proteinuria and abnormal sediment 1
Laboratory Screening
- Complete blood count (hemoglobin, platelets) 1
- Basic metabolic panel (creatinine, sodium, potassium) 1
- Lactate dehydrogenase and haptoglobin (to detect thrombotic microangiopathy) 1
- Urinalysis with microscopy 1
Management Algorithm for Hypertensive Urgency
Blood Pressure Reduction Strategy
Blood pressure should be reduced gradually over 24-48 hours, NOT acutely. 1, 3 Rapid blood pressure lowering in asymptomatic patients may be harmful and can precipitate cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation. 1, 3
Up to one-third of patients with diastolic blood pressure >95 mmHg normalize before arranged follow-up, and aggressive inpatient blood pressure treatment may be associated with worse outcomes including acute kidney injury and stroke. 1
Oral Antihypertensive Selection
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/ACE inhibitor) as third-line
Target Blood Pressure
Disposition and Follow-up
- Patients can be discharged even if blood pressure remains >180/110 mmHg IF there is no evidence of acute target organ damage 1
- Arrange outpatient follow-up within 2-4 weeks 1
- Initiating treatment for asymptomatic hypertension in the emergency department is not necessary when patients have adequate follow-up 1
Critical Pitfalls to Avoid
Do NOT Use IV Medications
Hypertensive urgency does not require hospital admission or IV medications—these are reserved exclusively for hypertensive emergencies with acute target organ damage. 1, 4
Do NOT Rapidly Lower Blood Pressure
Avoid aggressive acute blood pressure lowering, as this may cause cerebral, renal, or coronary ischemia through disruption of altered autoregulation in patients with chronic hypertension. 1, 3 Excessive acute drops >70 mmHg systolic can precipitate ischemic complications. 1
Do NOT Dismiss Neurological Symptoms
Do not assume unsteadiness is "benign" dizziness in the setting of hypertensive urgency—this symptom pattern increases likelihood of intracranial abnormalities and warrants MRI brain imaging. 2 The absence of focal deficits on examination does not exclude hypertensive encephalopathy, posterior reversible encephalopathy syndrome, or early stroke. 2
Do NOT Rely Solely on Blood Pressure Numbers
The presence or absence of acute target organ damage—not symptoms or blood pressure level—differentiates hypertensive emergency from urgency. 1 Many patients presenting with acute pain or distress have transiently elevated blood pressure that normalizes when the underlying condition is treated. 1
Do NOT Use Immediate-Release Nifedipine
Immediate-release nifedipine is contraindicated due to unpredictable precipitous blood pressure drops and reflex tachycardia. 1, 4
Post-Stabilization Management
After initial blood pressure control: 1
- Screen for secondary hypertension causes (found in 20-40% of malignant hypertension cases), including renal artery stenosis, pheochromocytoma, and primary aldosteronism 1
- Address medication non-adherence, the most common trigger for hypertensive crises 1
- Provide frequent follow-up (at least monthly) until target blood pressure is reached 1
- Consider fixed-dose single-pill combination treatment for long-term management 1