Management of Hypertensive Urgency

Definition and Clinical Presentation

Hypertensive urgency is defined as severe elevation in blood pressure (typically >180/120 mmHg) without evidence of new or progressive target organ damage, according to the American Heart Association and European Society of Cardiology 1, 2
Common presentations include severe headache, shortness of breath, epistaxis (nosebleeds), or severe anxiety, as reported by the American Heart Association 3
The majority of these patients are either non-compliant with their medications or inadequately treated hypertensives, as noted by the American Heart Association 3

Confirm blood pressure elevation with repeated measurements in both arms, as recommended by the American College of Physicians 4
Differentiate from hypertensive emergency by evaluating for signs of acute target organ damage (encephalopathy, stroke, acute heart failure, aortic dissection, etc.), according to the American Heart Association 1
Consider diagnostic testing to rule out end-organ damage: physical examination, fundoscopic exam, renal panel, and electrocardiogram, as suggested by the American College of Physicians 4

Reduce blood pressure by no more than 25% within the first hour, as recommended by the American Heart Association 3
Then, if stable, aim for BP <160/100-110 mmHg within the next 2-6 hours, according to the American Heart Association 3
Avoid short-acting nifedipine as it can cause unpredictable and excessive drops in blood pressure, as warned by the American Heart Association 3, 5
Recommended oral medications include captopril (ACE inhibitor), labetalol (combined alpha and beta-blocker), and nifedipine in extended-release formulation, as recommended by the European Society of Cardiology 2

An observation period of at least 2 hours is recommended to evaluate BP lowering efficacy and safety, as suggested by the European Society of Cardiology 2, 6
Excessive falls in pressure may precipitate renal, cerebral, or coronary ischemia and should be avoided, as cautioned by the American Heart Association 3

Patients with certain conditions require special consideration: ischemic stroke, aortic dissection, and patients requiring thrombolytic therapy, as noted by the American Heart Association 3
SBP should be lowered to 100 mmHg if tolerated in patients with aortic dissection, as recommended by the American Heart Association 3

Address medication adherence issues, as many hypertensive urgencies result from non-compliance, as reported by the American Heart Association 3
Screen for secondary causes of hypertension, especially in patients with recurrent hypertensive crises, as recommended by the European Society of Cardiology 7