In this episode, I’ll discuss oral antihypertensive timing for hypertensive urgency.
A hypertensive urgency is defined as a SBP reading of ≥180 mm Hg or DBP reading of ≥120 mm Hg without the presence of any end organ damage (such as but not limited to stroke, pulmonary edema, NSTEMI, AKI, aortic dissection, encephalopathy).
Guidelines for the management of hypertensive urgency have long recommended that treatment with oral antihypertensive is the desired first line therapy. However, in practice it is very common for a patient with hypertensive urgency to first receive IV antihypertensives despite guidelines recommending to use oral therapy.
In an effort to bring clarity around the optimal time to start oral antihypertensives in patients with hypertensive urgency, a group of authors published a descriptive study in AJHP.
220 patients were analyzed and stratified into quartiles based on the time to first administration of an oral antihypertensive from the time of hospital presentation. The first quartile represented patients who received oral antihypertensives earliest, and the fourth quartile represented patients who received oral antihypertensives later. To be included, patients had to at least receive an antihypertensive within 48 hours and they could not have had any end-organ damage that would have indicated a hypertensive emergency.
Roughly, the first quartile received an oral antihypertensive within 5 hours, the second quartile 5 to 8 hours, the third 8 to 15 hours, and the fourth quartile 15 to 48 hours.
The authors then looked at the change in systolic blood pressure from 12 to 24 hours and from 24 to 48 hours across the 4 quartiles.
For both time periods, patients in the first quartile had statistically significantly greater median reduction in SBP than those in the fourth quartile. In addition, the first quartile performed the same or better when compared to the second and third quartiles.
When the authors analyzed only those patients who received oral antihypertensives, the benefits in favor of the first quartile appeared similar to the full study cohort.
This improvement with faster starting of oral antihypertensives did not translate to a reduction in length of stay or adverse event rates, but it did increase the likelihood of achieving 3 consecutive SBP measurements at goal.
This study is limited by being a single-center retrospective analysis based on EMR data. However, the findings provide important confirmation that there is no need for IV antihypertensives in hypertensive urgency, and support earlier initiation of oral antihypertensives, especially within 5 hours after presentation to the hospital.
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