Hypertensive Emergency

Key considerations: Hypertensive encephalopathy, Aortic dissection, Acute heart failure / pulmonary edema

Cannot miss

history: Current medications and recent compliance; Stimulant use (cocaine, amphetamines); Symptoms: headache, visual changes, chest pain, dyspnea, confusion; Pregnancy status; Previous hypertensive crises; Diet: tyramine-containing foods with MAOIs; exam: BP in both arms (asymmetry suggests dissection); Fundoscopic exam: papilledema, hemorrhages, exudates; Cardiac: S3, S4, murmurs, JVD, crackles; Neurological: mental status, focal deficits, seizure signs; Pulmonary: crackles, wheezing (cardiac asthma); labs: BMP: creatinine, potassium (renal damage); CBC with peripheral smear (microangiopathic hemolytic anemia); Urinalysis: proteinuria, hematuria, casts; Troponin; BNP if heart failure suspected; LDH, haptoglobin, reticulocyte count if MAHA suspected; imaging: CXR: pulmonary edema, widened mediastinum; CT head if neurological symptoms (ICH, ischemic stroke, PRES); CT angiography if dissection suspected; Echocardiogram: LVH, wall motion, EF; bedside: 12-lead ECG: LVH, ischemia, strain pattern; Point-of-care echo: EF, wall motion, pericardial effusion; Point-of-care ultrasound lungs: B-lines (pulmonary edema)

immediate: Distinguish emergency (end-organ damage) from urgency (no end-organ damage); Arterial line for continuous BP monitoring in true emergency; IV antihypertensive drip — target 25% reduction in MAP in first hour; general: Do NOT reduce BP too rapidly — risk of watershed stroke; Target: reduce MAP by 25% in first hour, then to 160/100 over next 2–6 hours; Exception: aortic dissection — rapid BP reduction to SBP <120 and HR <60; specific: diagnosis: Hypertensive Encephalopathy; steps: Nicardipine drip 5–15 mg/hr or clevidipine; CT head to rule out hemorrhage; Gradual BP reduction, ICU admission; diagnosis: Aortic Dissection; steps: Esmolol drip or labetalol: target HR <60, SBP <120 within 20 min; Beta-blocker FIRST before vasodilator (prevent reflex tachycardia); Emergent CT angiography and surgical consult; diagnosis: Acute Pulmonary Edema; steps: Nitroglycerin drip + furosemide IV; BiPAP if respiratory distress; Reduce preload and afterload simultaneously; diagnosis: Eclampsia; steps: Magnesium sulfate 4–6g IV loading dose; Labetalol or hydralazine for BP control; Definitive treatment is delivery

admit: All hypertensive emergencies — ICU for continuous monitoring; Any evidence of end-organ damage; Requiring IV antihypertensive drip; discharge: Hypertensive urgency with no end-organ damage after observation; BP responds to oral medications in ED; Reliable follow-up within 24–48 hours; Restart or adjust home medications; consults: Cardiology: acute heart failure, dissection; Nephrology: acute kidney injury, MAHA; Neurology: encephalopathy, stroke; OB/GYN: eclampsia, pre-eclampsia

Hypertensive EMERGENCY = elevated BP + end-organ damage. Hypertensive URGENCY = elevated BP without end-organ damage
A BP of 220/120 in an asymptomatic patient with no end-organ damage is urgency, not emergency — do not give IV meds
For dissection: beta-blocker BEFORE vasodilator — nitroprusside alone causes reflex tachycardia and increases aortic shear stress
Never use sublingual nifedipine for hypertensive crisis — unpredictable drops cause stroke
Posterior reversible encephalopathy syndrome (PRES): headache, visual changes, seizures with hypertension — MRI shows posterior white matter edema

AHA/ACC Hypertension Guidelines 2017, ESC Hypertension Guidelines 2023. Last reviewed: 2024-11-01