Management of severe asymptomatic hypertension (hypertensive urgencies) in adults
- Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
- Professor of Acute and Continuing Care, The University of Texas Health Science Center at Houston
- Clinical Professor of Medicine, The University of Texas Medical Branch
- William J Elliott, MD, PhD
William J Elliott, MD, PhD
- Professor of Preventive Medicine, Internal Medicine and Pharmacology
- Head, Division of Pharmacology
- Chair, Department of Biomedical Sciences
- Pacific Northwest University of Health Sciences, Yakima, WA
- Section Editors
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
INTRODUCTION AND DEFINITION
Severe hypertension in adults (often defined as systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥110 mmHg) can be associated with a variety of acute, life-threatening complications, any one of which is considered a hypertensive emergency . These include hypertensive encephalopathy, retinal hemorrhages, papilledema, or acute and subacute kidney injury (table 1). A review of the manifestations and treatment of hypertensive emergencies is discussed separately. (See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults".)
Much more common, however, is the relatively asymptomatic or completely asymptomatic patient with a blood pressure in the "severe" range (ie, ≥180/≥110 mmHg), often a mild headache, but no signs or symptoms of acute end-organ damage. This entity of severe asymptomatic hypertension is called hypertensive urgency and, as with hypertensive emergencies, occurs more frequently among patients who have been nonadherent with either their chronic antihypertensive drug regimen or their low-sodium diet . Severe hypertension can also develop in medication-adherent patients following ingestion of large quantities of salt  and can be controlled by resuming a low-salt diet . (See "Initial evaluation of the hypertensive adult" and "Overview of hypertension in acute and chronic kidney disease".)
This topic reviews the treatment of severe asymptomatic hypertension, or hypertensive urgency. The recommendations below apply only to patients without signs of acute or ongoing end-organ damage.
The evaluation of patients with hypertension, the treatment of hypertensive emergencies, and the treatment of the pregnant woman with severe hypertension are discussed separately. (See "Initial evaluation of the hypertensive adult" and "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults" and "Evaluation and treatment of hypertensive emergencies in adults" and "Management of hypertension in pregnant and postpartum women" and "Expectant management of preeclampsia with severe features".)
The most important aspect of the initial assessment of the patient with severely elevated blood pressure is to exclude acute, ongoing, target-organ damage, which would indicate a diagnosis of hypertensive emergency rather than severe asymptomatic hypertension. (See "Evaluation and treatment of hypertensive emergencies in adults".)
- ESH/ESC Task Force for the Management of Arterial Hypertension. 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens 2013; 31:1925.
- Boudville N, Ward S, Benaroia M, House AA. Increased sodium intake correlates with greater use of antihypertensive agents by subjects with chronic kidney disease. Am J Hypertens 2005; 18:1300.
- Mishra SI, Jones-Burton C, Fink JC, et al. Does dietary salt increase the risk for progression of kidney disease? Curr Hypertens Rep 2005; 7:385.
- Pimenta E, Gaddam KK, Oparil S, et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial. Hypertension 2009; 54:475.
- Katz JN, Gore JM, Amin A, et al. Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: the Studying the Treatment of Acute hyperTension (STAT) registry. Am Heart J 2009; 158:599.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
- Zeller KR, Von Kuhnert L, Matthews C. Rapid reduction of severe asymptomatic hypertension. A prospective, controlled trial. Arch Intern Med 1989; 149:2186.
- Cherney D, Straus S. Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. J Gen Intern Med 2002; 17:937.
- O'Mailia JJ, Sander GE, Giles TD. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med 1987; 107:185.
- Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 1996; 276:1328.
- Handler J. Hypertensive urgency. J Clin Hypertens (Greenwich) 2006; 8:61.
- Patel KK, Young L, Howell EH, et al. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med 2016; 176:981.
- Levy PD, Mahn JJ, Miller J, et al. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med 2015; 33:1219.
- Narotam PK, Puri V, Roberts JM, et al. Management of hypertensive emergencies in acute brain disease: evaluation of the treatment effects of intravenous nicardipine on cerebral oxygenation. J Neurosurg 2008; 109:1065.
- Grassi D, O'Flaherty M, Pellizzari M, et al. Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles. J Clin Hypertens (Greenwich) 2008; 10:662.
- Kaplan NM. Chapter 8: Hypertensive crisis. In: Kaplan's Clinical Hypertension, 10th ed, Kaplan NM, Victor RG (Eds), Lippincott, Williams and Wilkins, Philadelphia 2009. p.274.
- Elliott WJ. Hypertensive emergencies. Crit Care Clin 2001; 17:435.
- Houston MC. The comparative effects of clonidine hydrochloride and nifedipine in the treatment of hypertensive crises. Am Heart J 1988; 115:152.
- Winker MA. The FDA's decisions regarding new indications for approved drugs. Where's the evidence? JAMA 1996; 276:1342.
- Souza LM, Riera R, Saconato H, et al. Oral drugs for hypertensive urgencies: systematic review and meta-analysis. Sao Paulo Med J 2009; 127:366.
- Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008; 359:2417.
- Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014; 32:3.
- INTRODUCTION AND DEFINITION
- Overall approach
- Rapidity of blood pressure lowering
- Blood pressure reduction goal
- Therapeutic strategies
- - When the pressure should be lowered over a period of hours
- - When the pressure should be lowered over a period of days
- Previously treated hypertension
- Untreated hypertension
- Monitoring and follow-up
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS