What are the most common causes of a hypertensive emergency?

From the Guidelines

Hypertensive emergencies are most commonly caused by uncontrolled or untreated essential hypertension, medication non-adherence, and secondary causes of hypertension, as well as acute manifestations of organ damage such as aortic dissection, myocardial ischemia, eclampsia, or heart failure, as outlined in the 2024 ESC guidelines 1. The causes of hypertensive emergencies can be categorized into several key areas, including:

• Uncontrolled or untreated essential hypertension
• Medication non-adherence, which can lead to rebound hypertension
• Secondary causes of hypertension, such as renal artery stenosis, pheochromocytoma, primary aldosteronism, and renal parenchymal disease
• Sympathomimetic substances, including cocaine, amphetamines, and synthetic cannabinoids
• Certain medications, such as NSAIDs, oral contraceptives, corticosteroids, and cyclosporine
• Pregnancy-related conditions, including preeclampsia and eclampsia
• Acute stress, pain, and anxiety, which can activate the sympathetic nervous system and precipitate hypertensive crises According to the most recent guidelines, hypertensive emergency is defined as a blood pressure of ≥180/110 mmHg associated with acute organ damage, often in the presence of symptoms, and requires immediate and careful intervention to reduce blood pressure, often with intravenous therapy 1. The management of hypertensive emergencies typically involves:
• Immediate blood pressure reduction with intravenous medications like labetalol, nicardipine, or clevidipine in a controlled setting
• Identifying and addressing the underlying cause of the hypertensive emergency
• Reducing blood pressure by approximately 25% within the first hour to avoid complications from too-rapid reduction, as recommended by the European Society of Cardiology 1 and the European Society of Hypertension 1.

From the Research

Causes of Hypertensive Emergency

• Non-compliance with medication, inadequate therapy, endocrine disease, renal disease, pregnancy, and intoxication are identified as the most important causes of hypertensive emergency 2
• Cardiovascular complications, including acute coronary syndrome, congestive heart failure, aortic dissection, and sympathomimetic hypertensive crises, are also associated with hypertensive emergency 3, 4
• Acute target organ damage, such as accelerated malignant hypertension, hypertensive encephalopathy, acute myocardial infarction, acute aortic dissection, acute left ventricular failure, and eclampsia, are characteristic of hypertensive emergencies 5

Common Forms of Target Organ Damage

• Pulmonary oedema/heart failure, acute coronary syndrome, ischaemic and haemorrhagic stroke are the most common forms of target organ damage in developed countries 6
• Hypertensive emergencies can also present with symptoms such as palpitations, headache, malaise, and a general feeling of illness, in addition to increased blood pressure 2

Key Considerations

• The management of hypertensive emergency depends on the presence or absence of organ manifestation, and the severity of the condition 2, 6
• Treatment includes rapid-acting medications to safely reduce blood pressure, protect remaining end-organ function, relieve symptoms, and minimize the risk of complications 3, 4, 5