Hypertensive emergency - Revision history

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← Revisión anterior		Revisión del 16:31 21 mar 2026
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	*[[Asymptomatic hypertension]]		*[[Asymptomatic hypertension]]
	*[[IV nitroglycerine alternatives]]		*[[IV nitroglycerine alternatives]]

			== Calculators ==
			{{MAP_Calculator}}

	==External Links==		==External Links==

Danbot: Add MedicationDose SMW annotations for all antihypertensives; dosing verified

2026-03-20T15:55:56Z

Add MedicationDose SMW annotations for all antihypertensives; dosing verified

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 **Evidence suggests potential harm from acute IV treatment of asymptomatic elevated BP<ref name="AHA2024"/>
 ==See Also==
 *[[Hypertension (main)]]

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2026-03-19T16:08:01Z

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	''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''		==Background==
			*''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''


	~~==Background==~~
	*Definition: acute target-organ damage due to severely elevated blood pressure		*Definition: acute target-organ damage due to severely elevated blood pressure
	**Blood pressure is generally ≥180/110-120, but presence of end-organ damage defines disease (not absolute blood pressure number)		**Blood pressure is generally ≥180/110-120, but presence of end-organ damage defines disease (not absolute blood pressure number)
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	''The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"''<ref name="AHA2024"/>		''The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"''<ref name="AHA2024"/>
	*'''Hypertensive emergency''': SBP ≥180 or DBP ≥110-120 mmHg '''with''' new or worsening target-organ damage		*'''Hypertensive emergency''': SBP ≥180 or DBP ≥110-120 mmHg '''with''' new or worsening target-organ damage
	*~~'''~~Asymptomatic markedly elevated BP~~'''~~: SBP ≥180 or DBP ≥110-120 mmHg '''without''' target-organ damage (replaces "hypertensive urgency")		*Asymptomatic markedly elevated BP: SBP ≥180 or DBP ≥110-120 mmHg '''without''' target-organ damage (replaces "hypertensive urgency")
	*~~'''~~Asymptomatic elevated BP~~'''~~: SBP >130 or DBP >80 mmHg without target-organ damage		*Asymptomatic elevated BP: SBP >130 or DBP >80 mmHg without target-organ damage

	===Etiology===		===Etiology===
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	===End-Organ Dysfunction (BARKH Mnemonic)<ref name="AHA2024"/><ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>===		===End-Organ Dysfunction (BARKH Mnemonic)<ref name="AHA2024"/><ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>===
	Use the '''BARKH''' mnemonic to systematically evaluate for target-organ damage:		Use the '''BARKH''' mnemonic to systematically evaluate for target-organ damage:
	*~~'''B'''rain~~		*Brain
	**[[Hypertensive encephalopathy]] (visual disturbances, [[seizure]], delirium)		**[[Hypertensive encephalopathy]] (visual disturbances, [[seizure]], delirium)
	**[[Intracranial hemorrhage]]		**[[Intracranial hemorrhage]]
	**Acute [[Stroke (Main)\|ischemic stroke]]		**Acute [[Stroke (Main)\|ischemic stroke]]
	*~~'''A'''rteries~~		*Arteries
	**[[Aortic dissection]]		**[[Aortic dissection]]
	*~~'''R'''etina~~		*Retina
	**High-grade [[hypertensive retinopathy]] (hemorrhages, exudates, papilledema)		**High-grade [[hypertensive retinopathy]] (hemorrhages, exudates, papilledema)
	*~~'''K'''idney~~		*Kidney
	**[[Acute kidney injury]] (often with microscopic hematuria)		**[[Acute kidney injury]] (often with microscopic hematuria)
	**[[Microangiopathic hemolytic anemia]] (MAHA) / thrombotic microangiopathy<ref>Cremer A, Amraoui F, Lip GY, et al. From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency. J Hum Hypertens. 2016;30(8):463-466. doi:10.1038/jhh.2015.82</ref>		**[[Microangiopathic hemolytic anemia]] (MAHA) / thrombotic microangiopathy<ref>Cremer A, Amraoui F, Lip GY, et al. From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency. J Hum Hypertens. 2016;30(8):463-466. doi:10.1038/jhh.2015.82</ref>
	*~~'''H'''eart~~		*Heart
	**Type-II [[myocardial infarction]] / unstable angina		**Type-II [[myocardial infarction]] / unstable angina
	**Acute LV failure with [[pulmonary edema]]		**Acute LV failure with [[pulmonary edema]]
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	====[[Aortic Dissection]]====		====[[Aortic Dissection]]====
	*Target SBP 100-120 and HR <60 within 20 min		*Target SBP 100-120 and HR <60 within 20 min
	*~~'''~~Beta-blockade BEFORE vasodilation~~'''~~ to prevent reflex tachycardia		*Beta-blockade BEFORE vasodilation to prevent reflex tachycardia
	**Esmolol (preferred for titratability) OR labetalol alone		**Esmolol (preferred for titratability) OR labetalol alone
	**Add nicardipine or clevidipine if BP remains elevated after adequate beta-blockade		**Add nicardipine or clevidipine if BP remains elevated after adequate beta-blockade
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	====[[Pulmonary Edema]]====		====[[Pulmonary Edema]]====
	*Reduce BP by 20-30%		*Reduce BP by 20-30%
	*~~'''~~Nitroglycerin~~'''~~ is drug of choice (reduces preload)		*Nitroglycerin is drug of choice (reduces preload)
	*Clevidipine or nicardipine are alternatives<ref>Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.</ref>		*Clevidipine or nicardipine are alternatives<ref>Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.</ref>
	*Promote diuresis AFTER vasodilation		*Promote diuresis AFTER vasodilation
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	====[[Cocaine]]/[[Amphetamine]] Toxicity====		====[[Cocaine]]/[[Amphetamine]] Toxicity====
	*~~'''~~[[Benzodiazepines]] first~~'''~~ (addresses underlying sympathetic surge)		*[[Benzodiazepines]] first (addresses underlying sympathetic surge)
	*If refractory: '''nicardipine''' or '''clevidipine''' (pure vasodilators)		*If refractory: '''nicardipine''' or '''clevidipine''' (pure vasodilators)
	*Phentolamine for refractory cases		*Phentolamine for refractory cases
	*~~'''~~Avoid pure beta-blockers~~'''~~ (risk of unopposed alpha-stimulation)		*Avoid pure beta-blockers (risk of unopposed alpha-stimulation)
	*Labetalol (mixed alpha/beta) remains debated; some guidelines permit, others advise against<ref>Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345-364. doi:10.3109/15563650.2016.1142090</ref>		*Labetalol (mixed alpha/beta) remains debated; some guidelines permit, others advise against<ref>Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345-364. doi:10.3109/15563650.2016.1142090</ref>

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	*Reduce BP by no more than 20%		*Reduce BP by no more than 20%
	*Avoid nitroprusside (cyanide metabolite accumulates in renal failure)		*Avoid nitroprusside (cyanide metabolite accumulates in renal failure)
	*~~'''~~Clevidipine~~'''~~ (organ-independent metabolism), '''nicardipine''', or '''fenoldopam''' (increases renal blood flow)		*Clevidipine (organ-independent metabolism), '''nicardipine''', or '''fenoldopam''' (increases renal blood flow)
	*Labetalol is an alternative		*Labetalol is an alternative

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	====[[Intracerebral Hemorrhage]]====		====[[Intracerebral Hemorrhage]]====
	*~~'''~~Target SBP <140 mmHg, initiated within 1 hour~~'''~~ (INTERACT3 care bundle)<ref name="INTERACT3">Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402(10395):27-40. doi:10.1016/S0140-6736(23)00806-1</ref>		*Target SBP <140 mmHg, initiated within 1 hour (INTERACT3 care bundle)<ref name="INTERACT3">Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402(10395):27-40. doi:10.1016/S0140-6736(23)00806-1</ref>
	*INTERACT3 demonstrated improved functional outcomes (OR 0.86, 95% CI 0.76-0.97) and reduced mortality with bundled care approach<ref name="INTERACT3"/>		*INTERACT3 demonstrated improved functional outcomes (OR 0.86, 95% CI 0.76-0.97) and reduced mortality with bundled care approach<ref name="INTERACT3"/>
	*Nicardipine, clevidipine, or labetalol		*Nicardipine, clevidipine, or labetalol
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	====[[Pheochromocytoma]]====		====[[Pheochromocytoma]]====
	*~~'''~~Alpha-blockade first~~'''~~: Phentolamine		*Alpha-blockade first: Phentolamine
	*Then add beta-blocker only after adequate alpha-blockade		*Then add beta-blocker only after adequate alpha-blockade
	*Nicardipine or clevidipine are alternatives		*Nicardipine or clevidipine are alternatives
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	==Disposition==		==Disposition==
	*'''Hypertensive emergency''': Admit to ICU or monitored setting for IV antihypertensive titration and close hemodynamic monitoring<ref name="AHA2025"/>		*'''Hypertensive emergency''': Admit to ICU or monitored setting for IV antihypertensive titration and close hemodynamic monitoring<ref name="AHA2025"/>
	*~~'''~~Asymptomatic markedly elevated BP~~'''~~ (formerly "urgency"):		*Asymptomatic markedly elevated BP (formerly "urgency"):
	**Do NOT treat with IV antihypertensives in the ED<ref name="AHA2024"/>		**Do NOT treat with IV antihypertensives in the ED<ref name="AHA2024"/>
	**Restart home medications		**Restart home medications

Ostermayer at 18:13, 16 March 2026

2026-03-16T18:13:42Z

Show changes

Rossdonaldson1: /* Video */

2024-04-17T20:09:53Z

Video

← Revisión anterior		Revisión del 20:09 17 abr 2024
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	*[http://www.emdocs.net/hypertensive-crisis-pearls-and-pitfalls-for-the-ed-physician/ emDocs - Hypertensive Emergency: Pearls and Pitfalls for the ED Physician]		*[http://www.emdocs.net/hypertensive-crisis-pearls-and-pitfalls-for-the-ed-physician/ emDocs - Hypertensive Emergency: Pearls and Pitfalls for the ED Physician]
	*[https://emcrit.org/ibcc/hypertensive-emergency/ EMCrit - Hypertensive Emergency]		*[https://emcrit.org/ibcc/hypertensive-emergency/ EMCrit - Hypertensive Emergency]

	~~==Video==~~
	~~{{#widget:YouTube\|id=KknXoRngPQM}}~~

	==References==		==References==

Logty: /* Diagnosis */

2021-10-05T13:14:13Z

Diagnosis

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	*Must have evidence of end-organ dysfunction		*Must have evidence of end-organ dysfunction
	**''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''		**''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''
	**''Symptoms such as headache,epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction''		**''Symptoms such as headache, epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction''

	==Management==		==Management==

Rossdonaldson1: /* Disposition */

2021-07-24T11:10:54Z

Disposition

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	==Disposition==		==Disposition==
	*Patients receiving titratable antihypertensive therapies will likely require admission to critical care unit		*Admit
	*Patients with asymptomatic hypertension may be discharged for outpatient management		**Patients receiving titratable antihypertensive therapies will likely require admission to critical care unit
	**Initiating oral antihypertensive agents from the ED is not usually necessary, but may be useful for select populations

	==See Also==		==See Also==

Rossdonaldson1: /* Management */

2021-07-24T11:08:36Z

Management

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	==Management==		==Management==
			'''High blood pressure without end organ damage is NOT hypertensive emergency (see [[asymptomatic hypertension]])'''
	*Goal: Lower mean arterial or systolic pressure by no more than 10-20% in the first hour<ref>Elliott WJ. Clinical features in the management of selected hypertensive emergencies. Prog Cardiovasc Dis. 2006;48(5):316-325. doi:10.1016/j.pcad.2006.02.004</ref>		*Goal: Lower mean arterial or systolic pressure by no more than 10-20% in the first hour<ref>Elliott WJ. Clinical features in the management of selected hypertensive emergencies. Prog Cardiovasc Dis. 2006;48(5):316-325. doi:10.1016/j.pcad.2006.02.004</ref>
	**Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours		**Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours

Rossdonaldson1: /* Clinical Features */

2021-07-24T11:05:46Z

Clinical Features

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	==Clinical Features==		==Clinical Features==
	'''End-Organ Dysfunction<ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>'''		'''End-Organ Dysfunction<ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>'''
	*Acute kidney injury		*[[Acute kidney injury]]
	**Often with microscopic hematuria		**Often with microscopic hematuria
	*Pulmonary edema		*[[Pulmonary edema]]
	*Type-II myocardial infarction		*Type-II [[myocardial infarction]]
	*Hypertensive encephalopathy		*[[Hypertensive encephalopathy]]
	**Visual disturbances		**Visual disturbances
	**Seizure		**[[Seizure]]
	**Delirium		**Delirium

← Revisión anterior		Revisión del 09:24 22 mar 2026
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	''The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"''<ref name="AHA2024"/>		''The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"''<ref name="AHA2024"/>
	*'''Hypertensive emergency''': SBP ≥180 or DBP ≥110-120 mmHg '''with''' new or worsening target-organ damage		*'''Hypertensive emergency''': SBP ≥180 or DBP ≥110-120 mmHg '''with''' new or worsening target-organ damage
	*Asymptomatic markedly elevated BP: SBP ≥180 or DBP ≥110-120 mmHg ~~'''~~without~~'''~~ target-organ damage (replaces "hypertensive urgency")		*Asymptomatic markedly elevated BP: SBP ≥180 or DBP ≥110-120 mmHg without target-organ damage (replaces "hypertensive urgency")
	*Asymptomatic elevated BP: SBP >130 or DBP >80 mmHg without target-organ damage		*Asymptomatic elevated BP: SBP >130 or DBP >80 mmHg without target-organ damage

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	==Clinical Features==		==Clinical Features==
	===End-Organ Dysfunction (BARKH Mnemonic)<ref name="AHA2024"/><ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>===		===End-Organ Dysfunction (BARKH Mnemonic)<ref name="AHA2024"/><ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>===
	Use the ~~'''~~BARKH~~'''~~ mnemonic to systematically evaluate for target-organ damage:		Use the BARKH mnemonic to systematically evaluate for target-organ damage:
	*Brain		*Brain
	**[[Hypertensive encephalopathy]] (visual disturbances, [[seizure]], delirium)		**[[Hypertensive encephalopathy]] (visual disturbances, [[seizure]], delirium)
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	*Ensure proper cuff size and technique before initiating treatment		*Ensure proper cuff size and technique before initiating treatment
	*Confirm with repeat measurement in both arms; patient should be seated, back supported, feet on floor		*Confirm with repeat measurement in both arms; patient should be seated, back supported, feet on floor
	*For patients receiving IV antihypertensives, ~~'''~~arterial line monitoring is preferred~~'''~~ for accuracy<ref name="AHA2024"/>		*For patients receiving IV antihypertensives, arterial line monitoring is preferred for accuracy<ref name="AHA2024"/>

	===Workup===		===Workup===
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	====[[Cocaine]]/[[Amphetamine]] Toxicity====		====[[Cocaine]]/[[Amphetamine]] Toxicity====
	*[[Benzodiazepines]] first (addresses underlying sympathetic surge)		*[[Benzodiazepines]] first (addresses underlying sympathetic surge)
	*If refractory: ~~'''~~nicardipine~~'''~~ or ~~'''~~clevidipine~~'''~~ (pure vasodilators)		*If refractory: nicardipine or clevidipine (pure vasodilators)
	*Phentolamine for refractory cases		*Phentolamine for refractory cases
	*Avoid pure beta-blockers (risk of unopposed alpha-stimulation)		*Avoid pure beta-blockers (risk of unopposed alpha-stimulation)
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	*Reduce BP by no more than 20%		*Reduce BP by no more than 20%
	*Avoid nitroprusside (cyanide metabolite accumulates in renal failure)		*Avoid nitroprusside (cyanide metabolite accumulates in renal failure)
	*Clevidipine (organ-independent metabolism), ~~'''~~nicardipine~~'''~~, or ~~'''~~fenoldopam~~'''~~ (increases renal blood flow)		*Clevidipine (organ-independent metabolism), nicardipine, or fenoldopam (increases renal blood flow)
	*Labetalol is an alternative		*Labetalol is an alternative

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	====[[CVA\|Ischemic Stroke]]====		====[[CVA\|Ischemic Stroke]]====
	*[[SAH]]: See [[Subarachnoid Hemorrhage (SAH)]]		*[[SAH]]: See [[Subarachnoid Hemorrhage (SAH)]]
	*If thrombolytic treatment is planned: goal SBP <185 and DBP <110 ~~'''~~before~~'''~~ administration<ref>Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211</ref>		*If thrombolytic treatment is planned: goal SBP <185 and DBP <110 before administration<ref>Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211</ref>
	*If no thrombolytics: consider BP reduction only if SBP >220 or DBP >120		*If no thrombolytics: consider BP reduction only if SBP >220 or DBP >120
	*Nicardipine, clevidipine, or labetalol are all effective and safe		*Nicardipine, clevidipine, or labetalol are all effective and safe