Pharmacologic Treatment of Hypertensive Urgency in the Outpatient Setting: A Systematic Review.

Campos CL, Herring CT, Ali AN, Jones DN, Wofford JL, Caine AL, Bloomfield RL, Tillett J, Oles KS.J Gen Intern Med. 2018 Apr;33(4):539-550. doi: 10.1007/s11606-017-4277-6. Epub 2018 Jan 16.PMID: 29340938 Free PMC article.

Abstract:

Background: Hypertensive urgency (HU), defined as acute severe uncontrolled hypertension without end-organ damage, is a common condition. Despite its association with long-term morbidity and mortality, guidance regarding immediate management is sparse. Our objective was to summarize the evidence examining the effects of antihypertensive medications to treat.

Methods: We searched the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Web of Science, Google Scholar, and Embase through May 2016. Study selection: We evaluated prospective controlled clinical trials, case–control studies, and cohort studies of HU in emergency room (ER) or clinic settings. We initially identified 11,223 published articles. We reviewed 10,748 titles and abstracts and identified 538 eligible articles. We assessed the full text for eligibility and included 31 articles written in English that were clinical trials or cohort studies and provided blood pressure data within 48 h of treatment. Studies were appraised for risk of bias using components recommended by the Cochrane Collaboration. The main outcome measured was blood pressure change with antihypertensive medications. Since studies were too diverse both clinically and methodologically to combine in a meta-analysis, tabular data and a narrative synthesis of studies are presented.

Results: We identified only 20 double-blind randomized controlled trials and 12 cohort studies, with 262 participants in prospective controlled trials. However, we could not pool the results of studies. In addition, comorbidities and their potential contribution to long-term treatment of these subjects were not adequately addressed in any of the reviewed studies.

Conclusions: Longitudinal studies are still needed to determine how best to lower blood pressure in patients with HU. Longer-term management of individuals who have experienced HU continues to be an area requiring further study, especially as applicable to care from the generalist.

Electronic supplementary material: The online version of this article (10.1007/s11606-017-4277-6) contains supplementary material, which is available to authorized users.

Summary:

            The systematic review I selected focuses on pharmacologic interventions for hypertensive urgency. Hypertensive urgency is defined as a SBP > 180 and a DBP > 120 without evidence of end organ damage. Although these are the proposed cutoff values for hypertensive urgency, in recent years, hypertensive urgency is being recognized as a “marked elevation in blood pressure” in patients with significant risk factors for end-organ damage such as CHF or CKD. According to my article, different classes of drugs can be used for lowering blood pressure in hypertensive urgency, though there is no clear benefit in rapid pharmacologic intervention. Calcium channel blockers, specifically amlodipine 5 and 10 mg, can reduce the MAP by 8-27 mmHg within the hour, respectively. ACE inhibitors, like captopril 25 mg, can decrease systolic blood pressure ~40 mmHg (from 244 to 177) in 12 hours. Beta Blockers such as PO Labetalol can decrease SBP by 41 mmHg in 4 hours. A combination of antihypertensive agents can be used to combat hypertensive urgency such as Labetalol plus furosemide. It is important to not exceed a 60 mmHg drop in SBP for patients with sustained chronic hypertension as a significant drop in BP from can prevent perfusion of the brain. Since my patient’s blood pressure was high, I would want to supplement her 10 mg of amlodipine with an ACEi or ARB. Typically, patients are prescribed amlodipine because they do not need to be monitored as closely for electrolyte imbalances. Maxing out the dose of amlodipine can cause edema, so it is important to prescribe another class as adjunctive therapy rather than titrating up. A combination of an ACEi/ARB and CCB provides cardiovascular and renal protection, making it an optimal combination.

Additional Source: https://www.ncbi.nlm.nih.gov/books/NBK513351/