What are the key differences in management between hypertensive emergency and hypertensive urgency in primary care?

Key differences in management between hypertensive emergency and hypertensive urgency in primary care revolve primarily around the presence of target organ damage and the urgency of intervention.

In hypertensive emergency, defined by a blood pressure of 180/120 mmHg or higher accompanied by signs of acute target organ damage (such as retinal hemorrhage, papilloedema, acute kidney injury, heart failure, or neurological symptoms), immediate referral for same-day specialist assessment is mandatory. This is because hypertensive emergencies require controlled but prompt blood pressure reduction using intravenous antihypertensives in a hospital setting to prevent further organ damage ¹. Primary care management is limited to urgent recognition and rapid referral rather than initiating treatment.

Conversely, hypertensive urgency involves severe hypertension (blood pressure ≥180/120 mmHg) without evidence of acute target organ damage. In this scenario, immediate hospital referral is not required. Instead, primary care should focus on confirming the diagnosis, assessing for target organ damage through investigations, and initiating or adjusting oral antihypertensive therapy as appropriate. Blood pressure reduction should be gradual to avoid precipitating ischemic events. Follow-up and monitoring are essential, with specialist referral considered if blood pressure remains uncontrolled or if target organ damage is subsequently identified ¹.

Recent literature supports this distinction, emphasizing that hypertensive emergencies necessitate rapid but controlled blood pressure lowering in a monitored setting, while hypertensive urgencies allow for more conservative management with oral agents and outpatient follow-up (Miller et al., 2024; Khan et al., 2024). There is no "magical" universal prescription; management must be tailored to the clinical context and presence of organ damage (Balahura et al., 2022).