Hypertensive urgency

A hypertensive urgency is a clinical situation in which blood pressure is very high (e.g., ≥180/≥110 mmHg) with minimal or no symptoms, and no signs or symptoms indicating acute organ damage.[1][2] This contrasts with a hypertensive emergency where severe blood pressure is accompanied by evidence of progressive organ or system damage.[1]

Treatment

In a hypertensive urgency blood pressure should be lowered carefully to ≤160/≤100 mmHg over a period of hours to days,[1] this can often be done as an outpatient.[2] There is limited evidence regarding the most appropriate rate of blood pressure reduction,[1] although it is recommended that mean arterial pressure should be lowered by no more than 25 to 30 percent over the first few hours.[3] Recommended medications for hypertensive urgencies include: captopril, labetalol, amlodipine, felodipine, isradipine, and prazosin.[4] Sublingual nifedipine is not recommended in hypertensive urgencies. This is because nifedipine can cause rapid decrease of blood pressure which can precipitate cerebral or cardiac ischemic events. There is also lack of evidence on the benefits of nifedipine in controlling hypertension.[4] Acute administration of drugs should be followed by several hours of observation to ensure that blood pressure does not fall too much. Aggressive dosing with intravenous drugs or oral agents which lowers blood pressure too rapidly carries risk;[5] conversely there is no evidence that failure to rapidly lower blood pressure in a hypertensive urgency is associated with any increased short-term risk.[3]

Epidemiology

Not much is known about the epidemiology of hypertensive urgencies. Retrospective analysis of data from 1,290,804 adults admitted to hospital emergency departments in United States from 2005 through 2007 found that severe hypertension with a systolic blood pressure ≥180 mmHg occurred in 13.8% of patients.[6] Based on another study in a US public teaching hospital about 60% of hypertensive crises are due to hypertensive urgencies.[7]

Risk factors for severe hypertension include older age, female sex, obesity, coronary artery disease, somatoform disorder, being prescribed multiple antihypertensive medications, and non-adherence to medication.[2]

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References
  1. "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults". www.uptodate.com. Retrieved 2017-12-02.
  2. Pak, Kirk J.; Hu, Tian; Fee, Colin; Wang, Richard; Smith, Morgan; Bazzano, Lydia A. (2014). "Acute hypertension: a systematic review and appraisal of guidelines". The Ochsner Journal. 14 (4): 655–663. ISSN 1524-5012. PMC 4295743. PMID 25598731.
  3. Chobanian, Aram V.; Bakris, George L.; Black, Henry R.; Cushman, William C.; Green, Lee A.; Izzo, Joseph L.; Jones, Daniel W.; Materson, Barry J.; Oparil, Suzanne (2003-05-21). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–2572. doi:10.1001/jama.289.19.2560. ISSN 0098-7484. PMID 12748199.
  4. Katalin, Mako; Corina, Ureche; Tirgu, Mures; Zsuzsanna, Jeremias (9 June 2018). "An Updated Review of Hypertensive Emergencies and Urgencies". Journal of Cardiovascular Emergencies. 4 (2): 73–83. doi:10.2478/jce-2018-0013.
  5. Yang, Jeong Yun; Chiu, Sophia; Krouss, Mona (2018-02-26). "Overtreatment of Asymptomatic Hypertension—Urgency Is Not an Emergency: A Teachable Moment". JAMA Internal Medicine. 178 (5): 704–705. doi:10.1001/jamainternmed.2018.0126. PMID 29482197.
  6. Shorr, Andrew F.; Zilberberg, Marya D.; Sun, Xiaowu; Johannes, Richard S.; Gupta, Vikas; Tabak, Ying P. (March 2012). "Severe acute hypertension among inpatients admitted from the emergency department". Journal of Hospital Medicine. 7 (3): 203–210. doi:10.1002/jhm.969. ISSN 1553-5606. PMID 22038891.
  7. Preston, R. A.; Baltodano, N. M.; Cienki, J.; Materson, B. J. (April 1999). "Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital". Journal of Human Hypertension. 13 (4): 249–255. doi:10.1038/sj.jhh.1000796. ISSN 0950-9240. PMID 10333343.
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