What is hypertension urgency?

What is Hypertensive Urgency

Hypertensive urgency is severely elevated blood pressure (>180/120 mmHg) WITHOUT acute target organ damage, and can be safely managed with oral medications and outpatient follow-up rather than hospitalization. 1, 2

Critical Distinguishing Feature

The presence or absence of acute target organ damage is the sole deciding factor that distinguishes hypertensive urgency from hypertensive emergency—not the blood pressure number itself. 2 This is the most important clinical determination you must make when evaluating any patient with severely elevated blood pressure.

Clinical Definition

• Hypertensive urgency is defined as systolic BP ≥180 mmHg and/or diastolic BP ≥110-120 mmHg without evidence of new or progressive acute target organ damage. 1, 2, 3
• The blood pressure threshold alone does not define urgency—you must actively exclude acute organ damage through systematic evaluation, not assume its absence based on lack of symptoms. 1

What You Must Exclude (Target Organ Damage)

To diagnose hypertensive urgency, you must systematically rule out acute damage in these organ systems:

Neurologic Damage

• Hypertensive encephalopathy (altered mental status, headache with vomiting, visual disturbances, seizures) 1, 2
• Acute ischemic stroke or intracranial hemorrhage 1, 2
• Perform brief neurological exam assessing mental status, visual changes, and focal deficits 1

Cardiac Damage

• Acute myocardial infarction or unstable angina 1, 2
• Acute left ventricular failure with pulmonary edema 1, 2
• Check for chest pain and obtain ECG 1

Renal Damage

• Acute kidney injury with deteriorating renal function 1, 2
• Thrombotic microangiopathy (check CBC, LDH, haptoglobin) 1
• Obtain creatinine and urinalysis 1

Ophthalmologic Damage

• Fundoscopy is essential—look for bilateral retinal hemorrhages, cotton wool spots, or papilledema (Grade III-IV retinopathy) defining malignant hypertension 1
• Isolated subconjunctival hemorrhage is NOT acute target organ damage 1

Vascular Damage

• Aortic dissection 1, 2

Management Approach

Hypertensive urgency does NOT require hospitalization, ICU admission, or IV medications. 1, 2

Appropriate Management

• Reinstitute or intensify oral antihypertensive therapy 2
• Arrange outpatient follow-up within 2-4 weeks 1, 2
• Reduce BP gradually over 24-48 hours, NOT acutely 1
• Patients can be discharged even if BP remains >180/110 mmHg IF there is no evidence of acute target organ damage and oral therapy is initiated or adjusted 1

What NOT to Do

• Do not admit to hospital or ICU 1, 2
• Do not use IV antihypertensive medications 1, 2
• Avoid rapid BP lowering in asymptomatic patients—this may cause cerebral, renal, or coronary ischemia in patients with chronic hypertension who have altered autoregulation 1, 2
• Do not treat the blood pressure number alone without assessing for true target organ damage 2

Important Clinical Context

• Up to one-third of patients with diastolic BP >95 mmHg normalize before arranged follow-up, and rapidly lowering BP in asymptomatic patients may be harmful. 1
• Patients with chronic hypertension often tolerate higher BP levels than previously normotensive individuals due to altered cerebral and renal autoregulation. 1
• The rate of BP rise may be more important than the absolute BP level. 1
• Many patients presenting with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated. 1

Prognosis

Patients with hypertensive urgency have worse cardiovascular risk profiles and reduced probability of BP control during follow-up, but the excess cardiovascular event risk appears mediated through BP control, non-BP cardiovascular risk factors, and demographic attributes rather than the urgency episode itself. 4