Hypertensive urgency

Hypertensive urgency is a severe and persistent elevation of blood pressure (BP) above 180/110 mmHg that is associated with significant symptoms such as headache or dizziness, or mild to moderate nonacute end-organ damage or dysfunctionNational Heart Foundation of Australia, 2016..

While hypertensive urgency is not immediately life threatening, referral to hospital is often required for investigations (eg electrocardiography, chest X-ray, urinalysis, liver biochemistry, kidney function tests) to exclude the presence of acute end-organ damage or dysfunction. Referral to hospital requires clinical judgement; always consider factors (eg pregnancy) that increase the risk of hypertensive complications—see Factors to consider in the management of severely elevated blood pressure.

Management with oral therapy is usually appropriate, aiming for relief of symptoms and a slow, nonprecipitous reduction of BP to a safe level (usually below 180 mmHg systolic initially) over several hours. Monitor the patient during this period.

For a patient who takes regular BP-lowering drugs but has not had their usual dose, it is reasonable to give the regular drugs, provided there are no acute contraindications.

In a patient without complications or risk factors (see Factors to consider in the management of severely elevated blood pressure), a gradual lowering of the elevated blood pressure with close monitoring is acceptable. For a patient who does not take regular BP-lowering drugs or who has not missed any doses of their regular drugs, give an oral dose of amlodipine and monitor the patient over 6 to 24 hours. Use:

Amlodipine has a delayed onset of action, so does not typically achieve a significant reduction in BP quickly. While a repeat dose may be given, do not give repeated doses of amlodipine over a short time as this may lead to a delayed precipitous fall in BP. Avoid the use of amlodipine to reduce BP if a rapid reduction is required.

For a patient who requires a more rapid reduction of elevated blood pressure (eg if symptoms are severe) or who has increased risk of hypertensive complications (see Factors to consider in the management of severely elevated blood pressure), use a drug that will start to reduce BP within 2 to 3 hours. When choosing a drug, consider causes, comorbidities and current drugs. Start with a low dose to avoid a precipitous fall in BP. Appropriate regimens include:

The choice of drug is determined by clinician familiarity and drug availability. The dose can be repeated if required, with consideration of the onset and duration of action of the drug.

Although transdermal glyceryl trinitrate patches are often used to reduce elevated BP (particularly in patients who are unable to take oral therapy), they are unlikely to produce a significant reduction in blood pressure.

If the patient is unable to take oral therapy, hospital admission for intravenous hydralazine may be a suitable alternative; see Hypertensive emergency for hydralazine dosage.

If the initial therapy successfully reduces BP (ideally to below 160 mmHg systolic, sustained over several hours and multiple BP readings) and symptoms resolve completely, consider sending the patient home to be followed up by their general practitioner the next day.

If symptoms are severe or ongoing, BP is difficult to control, follow-up is unlikely to occur or the patient has risk factors for hypertensive complications (see Factors to consider in the management of severely elevated blood pressure), admit the patient to hospital for management and monitoring. Consider referral to a specialised hypertension clinic if available.

Once the hypertensive urgency has resolved, consider starting or adjusting regular BP-lowering drugs. Further reduction towards a healthy long-term BP target can be achieved over the subsequent days and weeks. See Hypertension and blood pressure reduction for information on long-term management of BP.