|Other names: Severe asymptomatic hypertension; severe uncontrolled hypertension; severe uncomplicated hypertension|
|Symptoms||None, headache, nosebleed, leg swelling|
|Causes||Stopping blood pressure medication, stimulants, high thyroid, pain, anxiety|
|Differential diagnosis||Hypertensive emergency|
|Treatment||Treat anxiety, blood pressure medication by mouth with close outpatient follow up|
Hypertensive urgency is very high blood pressure, generally above 180 mmHg systolic or 110 mmHg diastolic, with no signs of organ damage. The diagnosis may apply despite a person having a headache, nosebleed, or leg swelling. It contrasts with hypertensive emergency where high blood pressure is accompanied by organ damage such as hypertensive encephalopathy, myocardial infarction, dissecting aortic aneurysm, kidney failure, or heart failure.
Most cases occur in people with known high blood pressure; often when they are not taking medication for the condition. Other causes may include the use of stimulants, high thyroid, pain, and anxiety. Other conditions that may appear similar include calcified arteries and improper measuring technique. Diagnosis may be based on symptoms and examination; with no further testing required. It requires ruling out a hypertensive emergency.
Treating anxiety, such as with benzodiazepines may lower blood pressure. If this is not sufficient often blood pressure medication by mouth with close outpatient follow up is recommended. Blood pressure should be reduced gradually. Other recommended measures include a low salt diet, no alcohol, stopping smoking, and weight loss. Without treatment, it is associated with a long-term risk of cardiovascular disease and death. Hypertensive urgency is relatively common, occurring in nearly 5% of family doctor visits and 3% of emergency department visits. Some view the term "hypertensive urgency" as inappropriate and suggest it be abandoned.
Hypertensive urgency is defined as severely high blood pressure with no evidence of end organ damage. As of 2022 the European Society of Cardiology; however, does not see the term as useful as it does not significantly differ from other types of asymptomatic high blood pressure.
The term "malignant hypertension", also known as accelerated hypertension, was included under this category with grade III/IV hypertensive retinopathy. In 2018, the European Society of Cardiology and the European Society of Hypertension put "malignant hypertension" under the category of "hypertensive emergency", which emphasizes poor outcomes if the condition is not treated urgently.
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.
In hypertensive urgency, blood pressure should be lowered gradually to ≤160/≤100 mmHg, this can often be done as an outpatient. There is limited evidence regarding the most appropriate rate of blood pressure reduction.
Medications that may be used include calcium-channel blockers, alpha-1 blockers, or mineralocorticoid receptor antagonists. Beta blockers and loop diuretics are generally not recommended initially.
Sublingual nifedipine is not recommended as it can cause rapid decrease of blood pressure which can precipitate ischemic events. Aggressive dosing with intravenous medications or oral agents which lowers blood pressure too rapidly carries risk; with no evidence that it improves outcomes as of 2023.
Not much is known about the epidemiology of hypertensive urgencies. An analysis of 1,290,804 adults who presented to emergency departments in United States from 2005 through 2007 found a systolic blood pressure ≥180 mmHg in 14%. Based on another study in a US public teaching hospital about 60% of hypertensive crises are due to hypertensive urgencies.
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