Hypertensive crises

Last updated: September 20, 2023

Summarytoggle arrow icon

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 kidney injury). 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.

Definitiontoggle arrow icon

  • Preferred terminology
    • Hypertensive crisis (acute severe hypertension): systolic blood pressure ≥ 180 mm Hg and/or diastolic blood pressure ≥ 120 mm Hg [1]
    • Hypertensive urgency: hypertensive crisis that is either asymptomatic or associated with isolated nonspecific symptoms (e.g., headache, dizziness, or epistaxis) without signs of acute organ damage [2][3]
    • Hypertensive emergency: hypertensive crisis with signs of acute end-organ damage, mainly in the cardiovascular, central nervous, and renal systems (see “Clinical features” below)
  • Historical terminology

Etiologytoggle arrow icon

Clinical featurestoggle arrow icon

Clinical features of hypertensive urgency

Clinical features of hypertensive emergency

Signs and symptoms of end-organ dysfunction

Suspect hypertensive encephalopathy in a patient presenting with diffuse neurological symptoms, severe hypertension, and nonspecific or normal neuroimaging. [7]

Red flags for hypertensive emergency

The following symptoms in a patient with severe hypertension should raise suspicion for a hypertensive emergency:

Additional clinical features that may be present

Management approachtoggle arrow icon

All patients

Hypertensive urgency

Hypertensive emergency

Patients without symptoms of a hypertensive emergency can usually be managed as outpatients and do not require emergency department evaluation. [8]

Diagnosticstoggle arrow icon

Evaluate for evidence of end-organ damage [6][8][9]

Testing should be targeted based on clinical suspicion (e.g., presence of red flags for hypertensive emergencies). [2][10]

In patients with asymptomatic severe hypertension, routine testing may not be required in the acute setting; follow local guidelines and protocols.

Additional evaluation to consider

Consider a urine pregnancy test to rule out preeclampsia in women of childbearing age.

Treatmenttoggle arrow icon

Approach [1][6]

Hypertensive urgency

  • Usually, no immediate intervention is required for asymptomatic patients.
  • Consider oral antihypertensive agents and monitoring if nonspecific symptoms are present.
  • See “Management of hypertensive urgency” for details.

Hypertensive emergencies

See “Management of hypertensive emergencies” for further information.

Most patients with hypertensive emergency require immediate IV antihypertensives and critical care.

Avoid lowering MAP by more than 25% within the first hour, except in special cases, as this can lead to hypoperfusion and ischemia in certain organs (e.g., brain, kidney, heart).

Management of hypertensive urgency [1][6]

Initial management

  • Asymptomatic patients: No immediate intervention is required. [2][6]
  • Nonspecific symptoms (e.g., isolated headache, nonspecific dizziness, epistaxis)
    • Move the patient to a quiet room for 30 minutes followed by repeat BP measurement. [6]
    • If symptoms persist and are attributable to high BP: Consider a rapid-acting oral antihypertensive agent. [2];
    • Monitor the patient for a few hours to ensure BP and symptoms improve.

Subsequent management and disposition

Most patients with asymptomatic severe hypertension have chronic poorly controlled hypertension. Acute lowering of blood pressure is usually not indicated in these patients and may be harmful. [2][10]

Management of hypertensive emergencies [1][6]

Initial management

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).

Intravenous antihypertensives [1]

Choice of agent depends on BP-lowering rate and targets, end-organ affected, underlying disorder, and patient comorbidities.

Agents by class

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.

Agents by underlying condition [1][6][8]

Associated condition Preferred antihypertensives [1] Additional considerations
Aortic dissection
Pulmonary edema
Acute coronary syndrome
Acute kidney injury
Catecholamine excess
Acute ischemic stroke
Acute intracerebral hemorrhage
Hypertensive encephalopathy [7]

Hypertensive pregnancy disorders

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

Acute management checklisttoggle arrow icon

All patients

Hypertensive urgency

  • Restart oral antihypertensive medication, if applicable (see “Antihypertensive therapy”).
  • Discharge home with close follow-up (within a week).

Hypertensive emergency

Prognosistoggle arrow icon

Referencestoggle arrow icon

  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): p.e13–e115.doi: 10.1161/hyp.0000000000000065 . | Open in Read by QxMD
  2. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  3. Peixoto AJ. Acute Severe Hypertension. N Engl J Med. 2019; 381 (19): p.1843-1852.doi: 10.1056/nejmcp1901117 . | Open in Read by QxMD
  4. Miller JB, Suchdev K, Jayaprakash N, et al. New Developments in Hypertensive Encephalopathy. Curr Hypertens Rep. 2018; 20 (2).doi: 10.1007/s11906-018-0813-y . | Open in Read by QxMD
  5. 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 . | Open in Read by QxMD
  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): p.59-68.doi: 10.1016/j.annemergmed.2013.05.012 . | Open in Read by QxMD
  7. Jacobs ZG. Hypertensive “Urgency” Is a Harmful Misnomer. J Gen Intern Med. 2021; 36 (9): p.2812-2813.doi: 10.1007/s11606-020-06495-6 . | Open in Read by QxMD
  8. Shantsila A, Lip GYH. Malignant Hypertension Revisited—Does This Still Exist?. Am Journal Hypertens. 2017; 30 (6): p.543-549.doi: 10.1093/ajh/hpx008 . | Open in Read by QxMD
  9. Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care. 2003; 7 (5): p.374-384.doi: 10.1186/cc2351 . | Open in Read by QxMD
  10. Breu AC, Axon RN. Acute Treatment of Hypertensive Urgency. J Hosp Med. 2018.doi: 10.12788/jhm.3086 . | Open in Read by QxMD

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