Hypertensive crisis
 |
Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2] Hafiz M. Ahmed, M.D.[3]
Synonyms and keywords: Hypertensive emergency; hypertensive urgency; severe hypertension
Overview
Hypertensive crisis is a term used to describe a severe elevation in the blood pressure which may or may not be associated with end-organ damage.[1] Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis.[2] Hypertensive crisis includes both hypertensive emergency and severe hypertension (previously termed hypertensive urgency). Severe hypertension is the severe elevation in the blood pressure without any evidence of acute end-organ damage. Hypertensive emergency mostly falls into stage 2 of hypertension. It is usually the severe elevation in the blood pressure (systolic blood pressure >180 mm Hg, or diastolic blood pressure >120 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.[3] The treatment of severe hypertension requires a gradual reduction in blood pressure over 24 to 48 hours. In hypertensive emergency, the treatment should be targeted to reduce the blood pressure by not more than 25% within the first hour; when blood pressure is stable, it should be reduced to 160/100-110 mmHg within the next 2 to 6 hours.[3]
Classification
Hypertensive crisis can be classified into severe hypertension (previously termed hypertensive urgency) and hypertensive emergency, depending on the absence or presence of acute target-organ damage.[1][4]
| Hypertensive crisis Acute elevation of blood pressure - Systolic blood pressure >180 mm Hg, or - Diastolic blood pressure >120 mm Hg | |||||||||||||||
| Hypertensive emergency Evidence of end organ damage | Severe Hypertension (formerly "Hypertensive Urgency") No evidence of end organ damage | ||||||||||||||
Severe Hypertension (formerly "Hypertensive Urgency")
Severe hypertension is severe elevation in blood pressure without evidence of acute target-organ damage. Historically referred to as hypertensive urgency, the 2025 AHA/ACC/Multispecialty Guideline has replaced the term "hypertensive urgency" with "severe hypertension" (defined as BP >180/120 mm Hg without evidence of acute target organ damage), as the prior terminology may imply a false sense of urgency that could encourage unnecessary aggressive treatment.[4]
Hypertensive Emergency
Hypertensive emergency mostly falls into stage 2 of hypertension (systolic blood pressure greater >160 mm Hg or diastolic blood pressure >100 mm Hg). It is usually an acute severe elevation in the blood pressure (systolic blood pressure >180 mm Hg, or diastolic blood pressure >120 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.[3]
Hypertensive Emergency as a Specific Term
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure of 120 mm Hg and above plus end organ damage (brain, cardiovascular, renal) (as described above) in contrast to severe hypertension where as yet no end organ damage has developed. The former requires immediate lowering of blood pressure such as with sodium nitroprusside infusions (NOT injections) while urgencies (about 3/4 of cases with diastolic blood pressure of 120 mm Hg and above) can be treated with parenteral administration (NOT oral) of labetalol or some calcium channel blockers. The former use of oral nifedipine, a calcium channel antagonist, has been strongly discouraged or banned because it is not absorbed in a controlled and reproducible fashion and has led to serious and fatal hypotensive problems.
Hypertensive Emergency as a Generic Term
Sometimes, although not very often, the term hypertensive emergency is also used as a generic term, comprising both hypertensive emergency as a specific term for a serious and urgent condition of elevated blood pressure and severe hypertension as a specific term of a less serious and less urgent condition (the terminology hypertensive crisis is usually used in this sense).
Causes
Life Threatening Causes
Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
Common Causes
- Antihypertensive medications withdrawal ( beta blockers, clonidine)
- Noncompliance with antihypertensive medications[2]
- Pheochromocytoma
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
- Phenylephrine
Causes by Organ System
| Cardiovascular | No underlying causes |
| Chemical/Poisoning | No underlying causes |
| Dental | No underlying causes |
| Dermatologic | No underlying causes |
| Drug Side Effect | Axitinib, Naphazoline, Naratriptan, Phendimetrazine, Sorafenib , Ziv-aflibercept |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | No underlying causes |
| Genetic | No underlying causes |
| Hematologic | No underlying causes |
| Iatrogenic | No underlying causes |
| Infectious Disease | No underlying causes |
| Musculoskeletal/Orthopedic | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional/Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | No underlying causes |
| Ophthalmologic | No underlying causes |
| Overdose/Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal/Electrolyte | No underlying causes |
| Rheumatology/Immunology/Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | No underlying causes |
Causes in Alphabetical Order
- List the causes of the disease in alphabetical order. You may need to list across the page, as seen here
Treatment
Management is directed by clinical practice guidelines[5]:
- "Hypertensive emergencies are defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage."
- "Severe hypertension is associated with severe BP elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction....Reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable. There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients"
Provide acute therapy for hypertensive emergency
For patients with end-organ damage and SBP >179 and DBP >119, the patient is suffering from hypertensive emergency. These patients should be admitted to the ICU and receive parenteral antihypertensive medications to avoid fluctuating drug levels from the oral or intramuscular routes. The recommended approach is to lower systolic blood pressure (SBP) to <140 mm Hg in most clinical scenarios, while in cases of aortic dissection, a more urgent target of SBP ≤120 mm Hg within approximately 20 minutes is advised. In patients with long-standing hypertension or markedly elevated initial SBP (>220 mm Hg), a more cautious strategy is preferred, aiming for an initial reduction of about 25% within the first hour, followed by gradual lowering over the subsequent 24–48 hours to prevent hypoperfusion due to impaired autoregulation. Notably, evidence indicates that early intensive SBP reduction to 110–139 mm Hg in patients without aortic dissection may be associated with a higher incidence of adverse renal events.[4]
Management of Severe Hypertension (formerly "Hypertensive Urgency")
Per the 2025 AHA/ACC/Multispecialty Guideline:
Patients with severe hypertension (blood pressure >180/120 mm Hg) who do not demonstrate evidence of acute target-organ damage should not undergo aggressive short-term blood pressure reduction or receive parenteral antihypertensive therapy. Instead, management should emphasize the reinstitution, adjustment, or escalation of oral antihypertensive medications, ideally with close outpatient follow-up.[4]
New Class 3 (Harm) Recommendation: In adults hospitalized for non-cardiac conditions who present with severe hypertension without evidence of acute target-organ injury, the intermittent administration of additional intravenous or oral antihypertensive agents to acutely lower blood pressure is not recommended. Observational evidence has linked this practice to adverse clinical outcomes, including higher in-hospital mortality, acute kidney injury, and prolonged hospitalization. These asymptomatic patients should instead be managed through careful blood pressure monitoring, continuation of scheduled antihypertensive therapy, and avoidance of reactive, as-needed antihypertensive dosing.[4]
Intravenous Antihypertensive Drugs
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.[3]
| Drug | Dose |
|---|---|
| Clevidipine | 1 to 2 mg/h as IV infusion; max 21 mg/h; max duration 72 h |
| Enalaprilat | 1.25–5 mg every 6 hrs IV; max 50 mg/24 h |
| Fenoldopam | 0.1–0.3 µg/kg per min IV infusion initially; max 1.6 µg/kg/min |
| Hydralazine | 10 mg slow IV infusion (max initial 20 mg), repeat every 4-6 hrs; max 200 mg/24 h |
| Nicardipine | Initial 5 mg/h, increase by 2.5 mg/h every 5 min to max 15 mg/h |
| Nitroglycerin | 5–100 µg/min as IV infusion; max 200 µg/min |
| Nitroprusside | 0.3–0.5 µg/kg/min as IV infusion initially; max 10 µg/kg/min |
| Esmolol | Bolus 500–1000 µg/kg/min over 1 min; then 50 mcg/kg/min infusion; max 300 µg/kg/min |
| Labetalol | Initial 0.3- to 1.0-mg/kg dose (maximum 20 mg) slow IV injection every 2 min, or 0.4–1.0 mg/kg/h IV infusion up to 3 mg/kg/h.
Maximum cumulative dose 300 mg/24 h |
| Phentolamine | 5 mg bolus, repeat every 10 min; max 50 mg/24 h |
According to the 2025 guideline, continuous infusion of short-acting, titratable antihypertensive agents is preferred in the intensive care setting to facilitate rapid blood pressure control while minimizing large hemodynamic fluctuations. Clinical studies suggest that intravenous nicardipine is more effective than labetalol in achieving short-term blood pressure targets, whereas clevidipine may provide faster blood pressure reduction compared with nicardipine. However, selection of the appropriate agent should be individualized based on the drug’s pharmacologic properties, the underlying cause of hypertension, the type and severity of target-organ injury, the desired pace of blood pressure reduction, and the patient’s comorbid conditions.[4]
Key Caution: Hydralazine is generally not recommended as a first-line agent for acute blood pressure management in most patients because of its variable hemodynamic response and relatively prolonged duration of action.
Oral Antihypertensive Drugs
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.[3]
| Drug | Dose |
|---|---|
| Captopril | 12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO |
| Clonidine | 0.1-0.2 mg PO x 1, then 0.05 to 0.1 mg/1-2 hrs. Max dose - 0.6 to 0.7 mg |
| Labetalol | 200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg |
- Other agents to consider include:
- PO frusemide 20mg (repeat as necessary)
- PO nifedipine SR 30mg, single dose
- PO felodipine 5 mg, single dose
Management of Specific Hypertensive Emergencies (Per 2025 Guidelines)
| Hypertensive emergencies | Preferred agents |
|---|---|
| Aortic dissection | Esmolol or labetalol
Note: Beta blockade should precede vasodilator prevent reflex tachycardia (e.g., nicardipine or nitroprusside) if needed
|
| Acute pulmonary edema | Clevidipine, nitroglycerin, nitroprusside
Note: Beta blockers are contraindicated |
| Acute coronary syndrome | Agents of Choice: Esmolol, nitroglycerin. Alternative options include labetalol and nicardipine.
Notes: Avoid nitrates in patients using PDE-5 inhibitors.
|
| Acute kidney injury | Clevidipine, fenoldopam, or nicardipine |
| Hypertensive encephalopathy | Nicardipine, labetalol, fenoldopam Note: the blood pressure should not be lowered by more than 25% within the first hour |
| Pre-eclampsia / eclampsia | Hydralazine, labetalol, nicardipine, or nifedipine.
Note: ACE inhibitors, ARBs, renin inhibitors, and nitroprusside are contraindicated. |
| Sympathetic crisis / cocaine overdose | Benzodiazepine + (verapamil, diltiazem, or nicardipine) Note: Beta blockers should NOT be administered alone to prevent un-opposed alpha-adrenergic stimulation |
| Sympathetic crisis / catecholamine excess (e.g., pheochromocytoma, postcarotid endarterectomy status) | Clevidipine, nicardipine, or phentolamine.
Note: Pheochromocytoma crisis should not be considered a compelling indication to reduce SBP to <120 or <140 mm Hg in the first hour. |
| Perioperative hypertension | Clevidipine, esmolol, nicardipine, or nitroglycerin |
| Acute intracerebral hemorrhage | Clevidipine, nicardipine, esmolol, labetalol, hydralazine
Note: For SBP 150–220 mm Hg, target SBP 130 to <140 mm Hg for at least 7 days; stop antihypertensives if SBP <130 mm Hg. |
| Acute ischemic stroke | Clevidipine, nicardipine, esmolol, labetalol, hydralazine Note: An expert's judgement is required to determine if the blood pressure should be lowered. |
| Withdrawal of antihypertensive therapy e.g. clonidine or propanolol | Re-administer the discontinued drug; phentolamine, nitroprusside, or labetalol, if necessary |
Prognosis
Patient may be at risk of readmission[6][7].
References
- ↑ 1.0 1.1 "The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V)". Arch Intern Med. 153 (2): 154–83. 1993. PMID 8422206. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Stewart, DL.; Feinstein, SE.; Colgan, R. (2006). "Hypertensive urgencies and emergencies". Prim Care. 33 (3): 613–23, v. doi:10.1016/j.pop.2006.06.001. PMID 17088151. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 3.2 3.3 3.4 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Writing Committee Members*, Jones, D. W., Ferdinand, K. C., Taler, S. J., Johnson, H. M., Shimbo, D., Abdalla, M., Altieri, M. M., Bansal, N., Bello, N. A., Bress, A. P., Carter, J., Cohen, J. B., Collins, K. J., Commodore-Mensah, Y., Davis, L. L., Egan, B., Khan, S. S., Lloyd-Jones, D. M., … Williamson, J. D. (2025). 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, 152(11), e114–e218. https://doi.org/10.1161/CIR.0000000000001356
- ↑ Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2018). "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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. 71 (6): e13–e115. doi:10.1161/HYP.0000000000000065. PMID 29133356.
- ↑ Kumar N, Simek S, Garg N, Vaduganathan M, Kaiksow F, Stein JH; et al. (2019). "Thirty-Day Readmissions After Hospitalization for Hypertensive Emergency". Hypertension. 73 (1): 60–67. doi:10.1161/HYPERTENSIONAHA.118.11691. PMC 6310036. PMID 30571563/ Check
|pmid=value (help). - ↑ Agarwal R (2019). "Rehospitalization Rates in Hypertensive Emergency". Hypertension. 73 (1): 49–51. doi:10.1161/HYPERTENSIONAHA.118.11789. PMC 6883922 Check
|pmc=value (help). PMID 30571571.