What is the research evidence base supporting the acute pharmacologic treatment of hypertensive urgencies?
Prevailing expert opinion from about 1950 to 2008 often recommended acute drug treatment for patients with very elevated blood pressures, but research produced no evidence of acute, ongoing target organ damage.
Courts ruled that physicians who evaluated but did not treat a patient with a hypertensive urgency were liable for any adverse outcome (e.g., stroke, myocardial infarction) shortly afterward.
Some felt that the hypertensive urgency was a “teachable moment” that would impress the patient with the importance of controlling blood pressure.
Then there were reports that acute hypotensive agents (especially nifedipine capsules) were temporally associated with ischemic events, perhaps because the blood pressure was lowered unpredictably and/or excessively. Recently two studies have compared long-term outcomes in patients presenting to either emergency departments ( n = 1016) or outpatient centers ( n = 59,535) with hypertensive urgencies; in neither report was acute drug treatment associated with improved prognosis. These data suggest that once acute, ongoing target organ damage is ruled out, the patient is best managed by timely referral to an appropriate source of outpatient care, where effective antihypertensive therapy can be prescribed and good follow-up assured.
