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hypertensive urgency

blood pressure > 180/110 without signs of end-organ damage Complications: - cardiovascular events rare (< 1%) [2] - 6 months later, most patients still with uncontrolled hypertension [2] Management: - resist the urge to abruptly lower blood pressure - check to see if blood pressure is properly measured & reproducible - if hospitalized, continue current therapy & monitor [8] - if outpatient, begin, restart or increase a long-acting agent, discharge home & follow up in 2-3 days if asymptomatic [5,7] - no need to lower blood pressure prior to discharge - prior recommendations to lower blood pressure & observe for several hours for a drop in blood pressure of 20-30 mm Hg is unnecessary [7] - oral furosemide, low-dose clonidine (0.1 mg) or captopril [5] - do not use sublingual clonidine [5] - do not use hydralazine to lower BP then discharge due to rebound hypertension after discharge - captopril 25 mg PO, followed in 90-120 minutes with incremental doses of 50 mg-100 mg [4]* - do not use IV antihypertensive in hospitalized patients [6] - urgent follow-up, within a couple of days - hospitalization does not improve prognosis [2] - adjust medications judiciously [3] * why the epiphany of elevated blood pressure * is the blood pressure likely to return to baseline in the 15-30 minutes for onset of captopril action? * 25 mg of captopril likely insufficient * 90-120 minute intervals may be impractical * what has happened since the previous blood pressure measurement? * captopril less likely than nifedipine to cause excessive drop in blood pressure [4] Notes: - if signs of end-organ damage, admit patient to MICU

Related

hypertensive crisis (malignant hypertension)

General

hypertension (HTN, high blood pressure, HBP)

References

  1. Prescriber's Letter 21(4): 2014 Management of Severe Hypertension Detail-Document#: 300423 (subscription needed) http://www.prescribersletter.com
  2. Patel KK, Young L, Howell EH et al Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med. Published online June 13, 2016 PMID: 27294333 http://archinte.jamanetwork.com/article.aspx?articleid=2527389 - Heath I Hypertensive Urgency - Is This a Useful Diagnosis? JAMA Intern Med. Published online June 13, 2016 PMID: 27295384 http://archinte.jamanetwork.com/article.aspx?articleid=2527384
  3. Yang JY, Chiu S, Krouss M. Overtreatment of Asymptomatic Hypertension - Urgency Is Not an Emergency. A Teachable Moment. JAMA Intern Med. Published online February 26, 2018 PMID: 29482197 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2673303
  4. NEJM Knowledge+ Question of the Week. Sept 18, 2018 https://knowledgeplus.nejm.org/question-of-week/15/
  5. Medical Knowledge Self Assessment Program (MKSAP) 18, 19 American College of Physicians, Philadelphia 2018, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  6. Ghazi L et al. Severe inpatient hypertension prevalence and blood pressure response to antihypertensive treatment. J Clin Hypertens (Greenwich) 2022 Mar; 24:339. PMID: 35174627 PMCID: PMC8925013 Free PMC article https://onlinelibrary.wiley.com/doi/10.1111/jch.14431 - Ghazi L et al. Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage. J Hypertens 2023 Feb 1; 41:288. PMID: 36583354 PMCID: PMC9799038 Free PMC article https://journals.lww.com/jhypertension/Fulltext/2023/02000/Effect_of_intravenous_antihypertensives_on.11.aspx
  7. Peixoto AJ Acute Severe Hypertension. N Engl J Med 2019. 381(19):1843-1852. Nov 7 PMID: 31693807
  8. NEJM Knowledge+ Cardiology - Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med 2020 Dec 28; PMID: 33369614 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2774562