← Diagnosis and Management Guides
Hypertensive Emergency
Key considerations: Aortic dissection, Hypertensive encephalopathy, Eclampsia
Cannot miss
- Aortic dissection
- Hypertensive encephalopathy
- Eclampsia
- Acute heart failure
- Intracranial hemorrhage
Likely diagnoses
- Hypertensive emergency (with end-organ damage)
- Hypertensive urgency (without end-organ damage)
- Pain/anxiety-driven hypertension
Red flags
- AMS
- Chest pain
- Back pain (dissection)
- Visual changes
- Papilledema
- Acute kidney injury
- Pulmonary edema
Workup
- history: Medications, compliance, symptoms of end-organ damage, cocaine/stimulant use; exam: Fundoscopic exam (flame hemorrhages, papilledema), neurologic exam, cardiac exam, bilateral BPs; labs: BMP (creatinine), troponin, CBC, urinalysis (proteinuria), coags; imaging: CXR (pulmonary edema, widened mediastinum); CT head if AMS or focal neuro deficits; CTA if dissection suspected; bedside: Continuous BP monitoring, ECG
Management
- immediate: IV antihypertensives: nicardipine, labetalol, or clevidipine drip; Target: 25% reduction in MAP in first hour, then toward 160/100 over next 2-6 hours; Aortic dissection: target HR <60 and SBP <120 rapidly with esmolol + nicardipine; general: Do NOT drop BP too quickly (risk of watershed infarct); Identify and treat underlying cause; Transition to oral antihypertensives when stable
Disposition
- admit: All hypertensive emergencies to ICU for IV drip and monitoring; discharge: Hypertensive urgency (no end-organ damage): adjust PO meds, follow-up in 24-72hr; consults: Cardiology if ACS/CHF, neurology if stroke, nephrology if AKI
Clinical pearls
- Hypertensive emergency = elevated BP + acute end-organ damage. Without organ damage, it is urgency.
- Do NOT use sublingual nifedipine — unpredictable rapid drops cause stroke
- Aortic dissection: reduce HR FIRST with beta-blocker, then add vasodilator — vasodilator alone causes reflex tachycardia
Source and review
- AHA/ACC Hypertension Guidelines 2017. Last reviewed: 2024-11-01