What is the management of hypertensive urgency?

From the Guidelines

Hypertensive urgency should be managed by gradually lowering blood pressure over 24-48 hours using oral medications rather than rapid reduction. This approach is supported by the most recent and highest quality study, which emphasizes the importance of avoiding rapid blood pressure reduction to prevent organ hypoperfusion, particularly in chronically hypertensive patients whose autoregulation has adapted to higher pressures 1.

Key Considerations

• Begin with amlodipine 5-10mg, labetalol 200-400mg twice daily, or captopril 25mg, depending on the patient's comorbidities.
• For patients with severe asymptomatic hypertension (>180/120 mmHg without end-organ damage), administer medication and observe for 1-2 hours before potential discharge with close follow-up within 24-72 hours.
• The goal is to reduce blood pressure by approximately 20-25% within the first day.
• Patients should be educated about medication adherence, lifestyle modifications including sodium restriction, and the importance of follow-up care.
• Underlying causes such as medication non-compliance, pain, anxiety, or substance use should be identified and addressed.

Distinguishing Hypertensive Urgency from Emergency

It is crucial to distinguish hypertensive urgency from hypertensive emergency, as the latter involves end-organ damage and requires immediate IV therapy in an intensive care setting 1. Hypertensive emergencies are defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage, and demand immediate reduction of BP to prevent or limit further target organ damage 1.

Management Approach

The management approach for hypertensive urgency should focus on gradual blood pressure reduction using oral medications, with close monitoring and follow-up to prevent complications and ensure optimal outcomes 1. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life, and is supported by the most recent and highest quality evidence.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Captopril tablets should be taken one hour before meals. Dosage must be individualized. Hypertension - Initiation of therapy requires consideration of recent antihypertensive drug treatment, the extent of blood pressure elevation, salt restriction, and other clinical circumstances If possible, discontinue the patient’s previous antihypertensive drug regimen for one week before starting captopril. For patients with severe hypertension (e.g., accelerated or malignant hypertension), when temporary discontinuation of current antihypertensive therapy is not practical or desirable, or when prompt titration to more normotensive blood pressure levels is indicated, diuretic should be continued but other current antihypertensive medication stopped and captopril dosage promptly initiated at 25 mg bid or tid, under close medical supervision When necessitated by the patient’s clinical condition, the daily dose of captopril may be increased every 24 hours or less under continuous medical supervision until a satisfactory blood pressure response is obtained or the maximum dose of captopril is reached.

The management of hypertensive urgency with captopril involves individualized dosage and consideration of the patient's clinical circumstances. The initial dose is 25 mg bid or tid, and the dose may be increased every 24 hours or less under close medical supervision until a satisfactory blood pressure response is obtained or the maximum dose is reached 2.

• Key points:
  • Initiation of therapy requires consideration of recent antihypertensive drug treatment and other clinical circumstances.
  • The dose may be increased every 24 hours or less under continuous medical supervision.
  • A diuretic may be continued, but other current antihypertensive medication should be stopped before starting captopril.
  • Close medical supervision is necessary when initiating captopril therapy, especially in patients with severe hypertension.

From the Research

Hypertensive Urgency Management

• Hypertensive urgency is a condition where the blood pressure is elevated (diastolic > 120 mmHg) with the absence of acute target organ disease 3.
• Hypertensive urgencies can usually be managed with oral agents, such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 3.
• Oral clonidine hydrochloride rapid titration or loading is a safe and effective method to control severe elevations of blood pressure in hypertensive crisis in many clinical situations 4.
• Comparative trials have demonstrated that four currently available oral agents (nifedipine, clonidine, captopril, and labetalol) can lower blood pressure rapidly and predictably 5.
• A randomized clinical trial comparing clonidine and captopril in patients with hypertensive urgency found that patients who received clonidine relieved significantly faster and experienced fewer side effects than those who received captopril 6.

Treatment Options

• Nifedipine and captopril have the most rapid onset of action, within 0.5-1 hour, and may be used to treat hypertensive emergencies as well as urgencies 5.
• Clonidine and labetalol have maximal blood pressure lowering effects at 2-4 hours 5.
• Agent selection should be based on the perceived need for urgent blood pressure control, the cause of hypertensive urgency, and concomitant conditions 5.

Important Considerations

• Immediate outpatient follow-up within 24 hours is mandatory in all patients who are not hospitalized to adjust the dose of antihypertensive medications 4.
• A definite benefit from acute blood pressure lowering in hypertensive urgencies has yet to be demonstrated, especially in asymptomatic patients 5.
• More controlled trials with less aggressive dosing regimens and placebo controls need to be performed to assess the most appropriate treatment for hypertensive urgencies with the fewest adverse effects 5.