• Clinical science
  • Clinician

Hypertensive crises

Summary

Hypertensive crises refer to acute increases in blood pressure (generally defined as ≥ 180/120 mm Hg) that cause or increase the risk of end-organ damage, i.e., damage to the brain (e.g., encephalopathy, stroke), eyes (e.g., retinopathy), cardiovascular system (e.g., ACS, pulmonary edema, aortic dissection), and/or kidneys (e.g., acute renal failure). They can be due to primary hypertension or precipitated by underlying conditions (e.g., pheochromocytoma, pre-eclampsia, drug toxicity). Management consists of rapidly identifying end-organ damage with patient history, physical examination, and focused testing, and determining whether the rapid lowering of the blood pressure with IV antihypertensives is required. The ideal IV antihypertensive agent is determined by the underlying disorder, end-organ systems affected, and other patient factors. In the absence of end-organ damage, hypertensive crises should be managed with rapid follow-up and oral antihypertensives, as the prognosis is poor if they are left untreated. See also hypertension.

Definition

Etiology

Clinical features

Hypertensive urgency

Hypertensive emergency

Additional clinical features that may be present

Approach

Approach to management

  1. Confirm blood pressure manually and on bilateral upper extremities.
  2. Determine if there are signs of end-organ damage.
    • Focused history/physical (see “Clinical features” below)
    • Select screening tests (see “Diagnostics” below)
  3. For hypertensive emergencies
    • ABCDE approach
    • Admit patients (ideally to ICU).
    • Lower the blood pressure acutely using IV agents and aim for targets based on the affected end-organs (see "Treatment" below).
    • Evaluate and treat underlying disorders.
  4. For hypertensive urgency
    • Select, reinstitute, or modify oral antihypertensive therapy.
    • In patients with a new diagnosis, evaluate for secondary causes of hypertension.
    • Arrange follow-up, monitoring, and counseling.

Red flags for hypertensive crisis

Diagnostics

Evaluate for signs of end-organ damage [3][4]

Additional evaluation to consider

Treatment

Hypertensive urgency [1][5]

Hypertensive urgency is usually caused by nonadherence to antihypertensive therapy. Aggressive intravenous antihypertensive therapy is not required.

Hypertensive emergency [1][5]

General principles

  • ICU admission and immediate initiation of intravenous antihypertensive therapy (see table below)
  • Continuous cardiac monitoring
  • Consider intra-arterial blood pressure monitoring.
  • Identify and treat any contributing comorbidities (e.g., chronic renal failure).
  • IV fluids if signs of volume depletion
  • Monitor BMP every 6 hours.

Rate and target of blood pressure reduction

Mean arterial pressure should not be lowered by more than 25% within the first hour, except in special cases. Reducing the blood pressure too rapidly can lead to hypoperfusion and ischemia in certain organs (e.g., brain, kidney, heart).

Choice of intravenous antihypertensive drugs

  • Consider the following factors when choosing an antihypertensive:
    • Desired rate of decrease in blood pressure
    • End-organ system affected
    • Underlying disorder
    • Presence or absence of comorbidities (e.g., heart failure, COPD)
    • Pharmacokinetics and adverse effects of the agent

Intravenous antihypertensives [1]

The response to and duration of action of IV hydralazine can be unpredictable. It should, therefore, be used with caution.

Because prolonged use of sodium nitroprusside carries a risk of cyanide toxicity, it should be limited in dose and duration of use.

Recommendations based on associated condition [1][4][5]

Associated condition Preferred intravenous antihypertensive [1] Additional considerations
Aortic dissection
Pulmonary edema
Acute coronary syndrome
Acute renal failure
Catecholamine excess
Acute ischemic stroke
Acute intracerebral hemorrhage
Eclampsia/severe pre-eclampsia

The drugs most commonly used to treat hypertensive emergencies are nitroprusside, labetalol, and nicardipine.

Acute management checklist

  • All patients
    • Confirm blood pressure manually and on bilateral upper and lower extremities.
    • Assess for signs of end-organ damage: BMP, LFTs, troponin, urinalysis, ECG, CXR (see “Diagnostics” above).
    • Identify and treat the underlying cause (e.g., medication nonadherence, pain, missed hemodialysis session).
  • Patients without end-organ damage
    • Restart oral antihypertensive medication, if applicable (see antihypertensive therapy).
    • Discharge home with close follow-up (within the next days, then monthly until BP is controlled).
  • Patients with signs of end-organ damage
    • Continuous cardiac monitoring
    • Consider intra-arterial blood pressure monitoring.
    • Treat any contributing comorbidities (e.g., chronic renal failure).
    • Consider CT head with/without contrast.
    • Consider CT/MRI chest with contrast if aortic dissection is suspected.
    • Start IV antihypertensive treatment based on patient comorbidities and end-organ involved (see “Treatment” above).
      • First hour: goal of reduction in mean arterial pressure by no more than 25%
      • Over the next 2–6 hours: Reduce to 160/100–110 mm Hg.
      • Once at goal (typically < 160/110 mm Hg): Transition to PO meds.
    • Consider IV fluids if there are signs of volume depletion.
    • Trend BMP every 6 hours.
    • Admit to the hospital.

Prognosis

  • 1. Whelton, PK, Carey, RM et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; 71(6): pp. e13–e115. doi: 10.1161/hyp.0000000000000065.
  • 2. Shantsila A, Lip GYH. Malignant Hypertension Revisited—Does This Still Exist?. American Journal of Hypertension. 2017; 30(6): pp. 543–549. doi: 10.1093/ajh/hpx008.
  • 3. Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care. 2003; 7(5): pp. 374–384. doi: 10.1186/cc2351.
  • 4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018; 138(17). doi: 10.1161/cir.0000000000000597.
  • 5. Peixoto AJ. Acute Severe Hypertension. N Engl J Med. 2019; 381(19): pp. 1843–1852. doi: 10.1056/nejmcp1901117.
  • 6. Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. Ann Emerg Med. 2013; 62(1): pp. 59–68. doi: 10.1016/j.annemergmed.2013.05.012.
  • Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. 2010; 121(13): pp. e266–369. doi: 10.1161/CIR.0b013e3181d4739e.
  • Hemphill JC, Greenberg SM, Anderson CS et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Stroke. 2015; 46(7). doi: 10.1161/STR.0000000000000069.
  • Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; 49(3). doi: 10.1161/str.0000000000000158.
  • Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Philadelphia, PA: Elsevier Health Sciences; 2018.
  • Breu AC, Axon RN. Acute Treatment of Hypertensive Urgency. Journal of Hospital Medicine. 2018. doi: 10.12788/jhm.3086.
last updated 11/19/2020
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