Hypertensive Urgency

Hypertensive urgency is a severe elevation of blood pressure, usually 180 mmHg or higher systolic and/or 120 mmHg or higher diastolic, without evidence of acute target organ damage.

It differs from hypertensive emergency, in which the same level of blood pressure is accompanied by acute damage to the brain, heart, aorta, kidneys, eyes or placenta that requires immediate intravenous treatment.

Most patients with hypertensive urgency are asymptomatic or have mild headache, and the risk of short term harm is low. They still need a safe plan to reduce pressure over days and ongoing control.

• Common causes: untreated or poorly controlled chronic hypertension (the majority), missed medicines or non-adherence, withdrawal of clonidine or beta blockers, NSAIDs, oral contraceptives, corticosteroids, decongestants (pseudoephedrine, phenylephrine), stimulants and recreational drugs (cocaine, amphetamines), alcohol, liquorice, ciclosporin, tacrolimus, erythropoietin, monoamine oxidase inhibitors with tyramine, pain, anxiety, urinary retention, sleep apnoea.
• Secondary hypertension: primary aldosteronism, renal parenchymal disease, renovascular disease, phaeochromocytoma, Cushing syndrome, thyroid disease, coarctation, pregnancy related hypertension.
• Populations at higher risk: people of African descent, older adults, diabetes, chronic kidney disease, obesity.
• Features of hypertensive emergency to exclude:
• Severe headache with confusion or seizures (encephalopathy), stroke, chest pain (acute coronary syndrome, aortic dissection), pulmonary oedema, acute kidney injury.
• Retinal haemorrhages, exudates or papilloedema, eclampsia and severe pre-eclampsia.

• Often asymptomatic, found on routine measurement. Possible headache, dizziness, epistaxis, anxiety, palpitations, nausea, blurred vision, mild chest tightness.
• Ask about duration of hypertension, adherence, missed doses, recent drugs and substances, pain, pregnancy, kidney disease, previous strokes or heart disease.
• Examination: repeat blood pressure in both arms with correct cuff size after 5 to 10 minutes of rest.
• Also examine pulse (rate, rhythm), fundi (haemorrhages, exudates, papilloedema) and cardiovascular system (heart failure signs, murmurs, carotid and femoral bruits, radio femoral delay).
• Examine chest (crackles), abdomen (renal bruit, masses, bladder) and neurology (focal signs, visual fields, confusion).
• Red flags (suggest emergency): neurological deficit, altered consciousness, seizures, severe headache with vomiting, chest or back pain, dyspnoea, pulmonary oedema, retinal haemorrhage with papilloedema, oliguria.
• Further red flags: vomiting with visual disturbance, pregnancy at 20 weeks or beyond or postpartum, proteinuria with hypertension, severe pain, phaeochromocytoma crisis (paroxysms of headache, sweating, palpitations and pallor), signs of aortic dissection.

• Measure the blood pressure properly (seated, supported arm, correct cuff size, two or more readings).
• Targeted tests to look for target organ damage: ECG (ischaemia, left ventricular hypertrophy), urinalysis (protein, blood, red cell casts), urea, creatinine, eGFR, electrolytes, glucose, full blood count.
• Add troponin if chest pain; chest X-ray if dyspnoea; fundoscopy; pregnancy test in women of reproductive age; urine drug screen if suspected.
• If no target organ damage: no further acute tests are required. Later: lipid profile, HbA1c, thyroid function, urine albumin creatinine ratio, echocardiography.
• Secondary hypertension screen where indicated (young age, resistant, sudden onset, hypokalaemia, abdominal bruit, episodic symptoms): aldosterone renin ratio, plasma or urine metanephrines, renal ultrasound with Doppler, overnight dexamethasone suppression test, sleep study.
• Differentials: white coat effect, pain or anxiety related spike, hypertensive emergency, pre-eclampsia, phaeochromocytoma, drug effect.

Principles

• Do not treat the number alone. Seat the patient in a quiet room, treat pain, anxiety, urinary retention and agitation, and recheck the blood pressure after 30 to 60 minutes.
• Lower the pressure gradually over 24 to 48 hours (first target below 160/100 mmHg within hours to days, then normal ranges over weeks). An abrupt fall can cause stroke, myocardial infarction and renal injury because cerebral, coronary and renal autoregulation are reset to higher pressures.
• Do not give sublingual or immediate release nifedipine capsules. Intravenous agents are not needed unless the patient has an emergency.
• Repeat the full assessment for target organ damage if any new symptom appears or the pressure fails to fall.

Outpatient treatment (asymptomatic, no target organ damage, reliable follow up)

• Restart the usual regimen and address missed doses, drug interactions and cost or supply barriers.
• If not on treatment: amlodipine 5 mg orally once daily, increased to 10 mg after 1 to 2 weeks.
• Alternatively use an ACE inhibitor (ramipril 2.5 mg once daily) or angiotensin receptor blocker (losartan 50 mg once daily) when pregnancy is excluded and renal function and potassium are acceptable.
• People of African descent respond best to amlodipine or a thiazide like diuretic (indapamide 1.5 mg modified release once daily).
• Review within 24 to 72 hours, then weekly until controlled.

Observed oral dose (clinic or emergency department, when non-adherence is the likely cause)

• Captopril 12.5 to 25 mg orally, repeated after 1 to 2 hours if needed; avoid in pregnancy, bilateral renal artery stenosis, hyperkalaemia and previous angioedema.
• Labetalol 100 to 200 mg orally, repeated after 1 to 2 hours (maximum 400 mg in the first session); avoid in asthma, heart block, bradycardia and acute heart failure.
• Clonidine 0.1 mg orally, repeated once after 1 hour only when other options are unsuitable (sedation; rebound hypertension if later stopped abruptly).
• Furosemide 20 to 40 mg orally when there is volume overload.
• Discharge only when the pressure has fallen, symptoms are absent and follow up within 72 hours is arranged.

Specific situations

• Cocaine or amphetamine use: diazepam 5 to 10 mg orally or lorazepam 1 to 2 mg orally first; avoid beta blockers used alone because of unopposed alpha stimulation; add amlodipine if pressure persists.
• Clonidine or beta blocker withdrawal: restart the previous drug at the usual dose and taper slowly later.
• Suspected phaeochromocytoma: do not start a beta blocker alone; arrange urgent specialist review with alpha blockade (phenoxybenzamine 10 mg twice daily or doxazosin 1 to 2 mg daily) before any beta blocker.
• NSAIDs, decongestants, liquorice, oral contraceptives and corticosteroids: stop or substitute the offending agent.
• Pain and urinary retention: analgesia (paracetamol 1 g every 6 hours) and catheterisation where needed.

Special groups

• Pregnancy at 20 weeks or beyond and postpartum: labetalol 200 mg orally or nifedipine modified release 10 to 20 mg orally, with urgent obstetric review the same day.
• Methyldopa 250 to 500 mg three times daily is an alternative in pregnancy.
• A pressure of 160/110 mmHg or higher in pregnancy is an obstetric emergency needing admission and intravenous treatment. Avoid ACE inhibitors and angiotensin receptor blockers.
• Children and adolescents: refer to paediatrics the same day; if observation is needed, amlodipine 0.1 mg/kg orally once daily (maximum 5 mg initially) under specialist direction.
• Older adults: start low (amlodipine 2.5 mg once daily) and lower the pressure over several days to avoid cerebral hypoperfusion and falls.
• Chronic kidney disease: amlodipine or labetalol first; check creatinine and potassium within 1 week of starting an ACE inhibitor or angiotensin receptor blocker; furosemide 40 to 80 mg for volume overload.
• Diabetes: use an ACE inhibitor or angiotensin receptor blocker when albuminuria is present, and avoid thiazide like diuretic at high doses.

Long term regimen once stable

• Step 1: ACE inhibitor (ramipril 2.5 to 10 mg daily; lisinopril 10 to 40 mg daily) or angiotensin receptor blocker (candesartan 8 to 32 mg daily; losartan 50 to 100 mg daily); in people of African descent or aged over 55, a calcium channel blocker (amlodipine 5 to 10 mg daily).
• Step 2: add a calcium channel blocker or the ACE inhibitor or angiotensin receptor blocker.
• Step 3: add a thiazide like diuretic (indapamide 1.5 mg modified release daily; chlortalidone 12.5 to 25 mg daily).
• Resistant hypertension: confirm adherence and exclude secondary causes, then add spironolactone 25 to 50 mg daily (check potassium and creatinine at 1 and 4 weeks), then a beta blocker or an alpha blocker (doxazosin 1 to 8 mg daily).

Admission

• Admit for any target organ damage, pregnancy, children, severe symptoms, inability to ensure follow up or supply of medicines, suspected secondary cause needing in hospital workup, or a markedly raised pressure with poor response to oral treatment.

Lifestyle

• Salt below 5 to 6 g daily, weight loss, a diet rich in fruit, vegetables and low fat dairy, regular exercise (150 minutes weekly), alcohol within limits, stop smoking, and avoid NSAIDs, decongestants and stimulants.
• Home blood pressure monitoring with a validated upper arm cuff (target below 135/85 mmHg on home readings).

Follow up and safety advice

• Review within 24 to 72 hours, then weekly until controlled; check renal function and potassium 1 to 2 weeks after starting or changing an ACE inhibitor, angiotensin receptor blocker or diuretic.
• Return immediately for chest pain, severe headache, weakness, visual loss, confusion, shortness of breath or seizures.