Hypertensive Emergency

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quick reference

Definition: severe elevations in BP (typically >180/120 mm Hg) associated with evidence of acute target organ damage

Better Definition: chief complaint indicating severe underlying pathology

1. Is there a know cause of HTN? Treat as such (secondary HTN)
   1. PRES
   2. Aortic Dissection
   3. SAH
   4. Non-traumatic ICH
   5. Ischemic Stroke
   6. SCAPE
   7. ACS
   8. Pregnancy-related hypertensive emergency
2. No known cause + target organ damage = hypertensive emergency

Workup:

• CBC
• CMP
• Chest X-ray
• EKG
• Imaging: depends on suspicion (CT head, CTA chest, etc)

	Brain	Arteries	Retina	Kidney	Heart
Acute conditions indicating hypertensive emergency	- Stroke - Hypertensive encephalopathy (PRES) - Intracerebral hemorrhage	-Acute aortic dissection -Preeclampsia -HELLP -Eclampsia	Grade III–IV Keith-Wagener-Barker hypertensive retinopathy	Acute kidney injury Thrombotic microangiopathy	Acute heart failure Pulmonary edema Acute coronary syndrome
Initial BP target	130<SBP<180 mm Hg, MAP decline 15% in 1 h Immediate MAP decline 20%–25% Immediate MAP decline 15%	SBP <120 mm Hg immediate Immediate SBP <160 mm Hg and DBP <105 mm Hg if severe	SBP <180 mm Hg MAP decline of 15%	MAP decline 20%–25% over several hours	SBP <180 mm Hg or MAP decline 25% Immediate SBP <140 mm Hg Immediate SBP <140 mm Hg
Treatment agents	Labetalol Nicardipine	Esmolol and nitroprusside, nitroglycerin, or nicardipine Labetalol, nicardipine, magnesium sulfate, or hydralazine		Labetalol Nicardipine Clevidipine Fenoldopam	Nitroglycerin Nitroprusside Labetalol Clevidipine Esmolol

IV Antihypertensives

Type	Duration	Meds
Titratable Agents	<30min	Esmolol, Clevidipine, Nitroglycerin, Nitroprusside
Semi-titratable agents	<1-2hrs	Nicardipine, Diltiazem
Bolus Agents	>1-2hrs	Labetolol, Metoprolol, Hydralazine

Pathology	Ideal Antihypertensive (Primary/Secondary/Adjuncts)	BP Goal
Aortic Dissection	Esmolol / diltiazem / nicardipine/clevidipine	SBP <100-120
PRES	Clevidipine / Nicardipine	~160/100
Subarachnoid Hemorrhage	Nicardipine / Enalapril / oral nimodipine	SBP <160
Non-traumatic ICH	nicardipine / esmolol	SBP ~140
SCAPE	nitroglycerin
Ischemic Stroke	clevidipine / nicardipine	<185/110 (TPA)
ACS	nitroglycerin / nicardipine / clevidipine
Pregnancy-related	hydralazine / labetolol / ALWAYS magnesium	<140/90

Simplified Summary

• When in doubt, choose CCB (Clevidipine / Nicardipine)
• ACS / SCAPE = nitroglycerin / CCB
• Aortic Dissection = esmolol / CCB

Guidelines / Resources

The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association | Hypertension

2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines | Circulation

Hypertensive emergency & antihypertensive medications - EMCrit Project

Microsoft Word - Hypertensive Emergencies.docx