Hypertensive urgency explained

A hypertensive urgency is a clinical situation in which blood pressure is very high (e.g., 220/125 mmHg) with minimal or no symptoms, and no signs or symptoms indicating acute organ damage.^[1] This contrasts with a hypertensive emergency where severely high blood pressure is accompanied by evidence of progressive organ or system damage.__TOC__

Definition

Hypertensive urgency is defined as severely high blood pressure with no evidence of end organ damage.^[2] The term "malignant hypertension" was also included under this category with grade III/IV hypertensive retinopathy.^{[3] [4]} However, in 2018, European Society of Cardiology and the European Society of Hypertension issued a new guideline which put "malignant hypertension" under the category "hypertensive emergency", which emphasize on poor outcome if the condition is not treated urgently.^{[2] [5]}

Treatment

In a hypertensive urgency blood pressure should be lowered carefully to ≤160/≤100 mmHg over a period of hours to days,^[6] this can often be done as an outpatient. There is limited evidence regarding the most appropriate rate of blood pressure reduction, although it is recommended that mean arterial pressure should be lowered by no more than 25 to 30 percent over the first few hours.^[7] Recommended medications for hypertensive urgencies include: captopril, labetalol, amlodipine, felodipine, isradipine, and prazosin.^[8] 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.^[8] 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;^[9] conversely there is no evidence that failure to rapidly lower blood pressure in a hypertensive urgency is associated with any increased short-term risk.

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.^[10] Based on another study in a US public teaching hospital about 60% of hypertensive crises are due to hypertensive urgencies.^[11]

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.

Notes and References

1. Pak KJ, Hu T, Fee C, Wang R, Smith M, Bazzano LA . Acute hypertension: a systematic review and appraisal of guidelines . The Ochsner Journal . 14 . 4 . 655–663 . 2014 . 25598731 . 4295743 .
2. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GY, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I . 6 . 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension . Journal of Hypertension . 36 . 10 . 1953–2041 . October 2018 . 30234752 . 10.1097/HJH.0000000000001940 .
3. Kitiyakara C, Guzman NJ . Malignant hypertension and hypertensive emergencies . Journal of the American Society of Nephrology . 9 . 1 . 133–142 . January 1998 . 9440098 . 10.1681/ASN.V91133 . free .
4. Henderson AD, Biousse V, Newman NJ, Lamirel C, Wright DW, Bruce BB . Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure . The Western Journal of Emergency Medicine . 13 . 6 . 529–534 . December 2012 . 23359839 . 3555579 . 10.5811/westjem.2011.10.6755 .
5. Shantsila A, Lip GY . Malignant Hypertension Revisited-Does This Still Exist? . American Journal of Hypertension . 30 . 6 . 543–549 . June 2017 . 28200072 . 10.1093/ajh/hpx008 . free .
6. Web site: Varon J, Elliott WJ . 17 November 2021 . Bakris GL, White WB, Forman JP . Management of severe asymptomatic hypertension (hypertensive urgencies) in adults. www.uptodate.com. 2017-12-02.
7. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, Roccella EJ . 6 . 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 . May 2003 . 12748199 . 10.1001/jama.289.19.2560 .
8. Makó K, Ureche C, Mures T, Jeremiás Z . An Updated Review of Hypertensive Emergencies and Urgencies . Journal of Cardiovascular Emergencies . 9 June 2018 . 4 . 2 . 73–83 . 10.2478/jce-2018-0013. free .
9. Yang JY, Chiu S, Krouss M . Overtreatment of Asymptomatic Hypertension-Urgency Is Not an Emergency: A Teachable Moment . JAMA Internal Medicine . 178 . 5 . 704–705 . May 2018 . 29482197 . 10.1001/jamainternmed.2018.0126 .
10. Shorr AF, Zilberberg MD, Sun X, Johannes RS, Gupta V, Tabak YP . Severe acute hypertension among inpatients admitted from the emergency department . Journal of Hospital Medicine . 7 . 3 . 203–210 . March 2012 . 22038891 . 10.1002/jhm.969 . free .
11. Preston RA, Baltodano NM, Cienki J, Materson BJ . Clinical presentation and management of patients with uncontrolled, severe hypertension: results from a public teaching hospital . Journal of Human Hypertension . 13 . 4 . 249–255 . April 1999 . 10333343 . 10.1038/sj.jhh.1000796 . free .