What is the recommended management for a hypertensive urgency (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg) without evidence of acute target‑organ damage?

Management of Hypertensive Urgency

Hypertensive urgency (BP ≥180/120 mmHg without acute target-organ damage) should be managed with oral antihypertensive medications and outpatient follow-up within 2–4 weeks—hospital admission and intravenous therapy are not indicated. 1, 2

Critical First Step: Exclude Hypertensive Emergency

Before labeling a patient as "hypertensive urgency," you must actively rule out acute target-organ damage, because the presence of such damage converts the scenario to a hypertensive emergency requiring ICU admission and IV therapy. 1

Assess for Target-Organ Damage

Perform a focused examination looking for:

• Neurologic: altered mental status, headache with vomiting, visual disturbances, seizures, focal deficits, or somnolence 1
• Cardiac: chest pain suggesting acute myocardial ischemia/infarction, acute heart failure, or pulmonary edema 1
• Vascular: symptoms of aortic dissection (tearing chest/back pain, pulse differential) 1
• Renal: acute rise in creatinine, oliguria 1
• Ophthalmologic: perform fundoscopy to look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III–IV retinopathy defining malignant hypertension) 1
• Obstetric: severe preeclampsia or eclampsia 1

If any of these are present, the patient has a hypertensive emergency and requires immediate ICU transfer with IV antihypertensive therapy. 1

Management Algorithm for Confirmed Hypertensive Urgency

Once you have confirmed the absence of acute target-organ damage, proceed with oral therapy:

Oral Antihypertensive Selection

For non-Black patients:

• Start a low-dose ACE inhibitor (e.g., captopril 12.5–25 mg) or ARB 1
• Add a dihydropyridine calcium-channel blocker (e.g., extended-release nifedipine 30–60 mg) if needed 1
• Add a thiazide or thiazide-like diuretic as third-line 1

For Black patients:

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

Blood Pressure Targets and Timeline

• Target BP: <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) 1, 2
• Timeline: Achieve target within 3 months 1
• Acute reduction: Lower BP gradually over 24–48 hours, NOT acutely 1, 2

Patients can be discharged even if BP remains >180/110 mmHg at the time of discharge, provided there is no evidence of acute target-organ damage and oral therapy has been initiated or adjusted. 1

Follow-Up

• Arrange outpatient follow-up within 2–4 weeks 1, 2
• Reassess BP control and titrate medications as needed 2

Critical Pitfalls to Avoid

Do Not Admit Without Target-Organ Damage

Admitting patients with asymptomatic severe hypertension in the absence of acute target-organ damage is inappropriate. 1 Up to one-third of patients with diastolic BP >95 mmHg normalize before arranged follow-up, and rapid BP lowering in asymptomatic patients may be harmful. 1

Do Not Use IV Medications

Hypertensive urgency does not require IV therapy; oral agents are appropriate and safer. 1, 2

Do Not Lower BP Rapidly

Rapid BP reduction in hypertensive urgency may cause cerebral, renal, or coronary ischemia, particularly in patients with chronic hypertension who have altered autoregulation. 1, 2 The rate of BP rise may be more important than the absolute value in determining risk. 2

Avoid Immediate-Release Nifedipine

Never use immediate-release nifedipine because it causes unpredictable precipitous BP drops, stroke, and death. 1 Only extended-release formulations are acceptable. 1

Do Not Overlook Secondary Causes

After stabilization, screen for secondary hypertension (renal-artery stenosis, pheochromocytoma, primary aldosteronism, renal parenchymal disease), especially in younger patients or those with resistant hypertension, as 20–40% of patients with malignant hypertension have identifiable secondary causes. 1, 2

Special Populations

Patients with Heart Failure (EF <40%)

Prioritize ACE inhibitor or ARB, add beta-blocker, and add aldosterone receptor antagonist if EF <40%. 2

Patients with Cardiovascular Disease

Target systolic BP 120–129 mmHg to reduce cardiovascular risk. 2 Consider fixed-dose single-pill combination treatment (RAS blocker + calcium-channel blocker + diuretic) to improve adherence. 2

Addressing Medication Non-Adherence

Medication non-adherence is the most common trigger for hypertensive emergencies. 1 Address barriers to adherence, simplify regimens, and consider single-pill combinations. 1