At what point should a patient with hypertensive crisis be sent to the emergency department for evaluation and treatment?

When to Send Your Patient to the Emergency Department

Send your patient to the emergency department immediately if they have blood pressure >180/120 mmHg AND any signs or symptoms of acute target organ damage—this is a hypertensive emergency requiring ICU-level care with IV medications. 1

Critical Decision Point: Emergency vs. Urgency

The key distinction is not the blood pressure number alone, but whether acute organ damage is present: 1, 2

Hypertensive Emergency (Send to ED immediately):

• BP >180/120 mmHg PLUS any of the following: 1, 3
  • Neurologic: Severe headache with altered mental status, seizures, visual changes, focal deficits, lethargy, cortical blindness, or coma 1, 3
  • Cardiac: Chest pain (acute MI or unstable angina), acute heart failure with pulmonary edema, shortness of breath 1
  • Vascular: Symptoms suggesting aortic dissection (tearing chest/back pain) 1, 3
  • Renal: Acute kidney injury (oliguria, rising creatinine) 1
  • Ophthalmologic: Papilledema, retinal hemorrhages, cotton wool spots on fundoscopy 1, 3
  • Hematologic: Signs of hemolysis or thrombocytopenia (thrombotic microangiopathy) 1, 3

Untreated hypertensive emergencies have a 1-year mortality rate exceeding 79% with median survival of only 10.4 months. 1, 3

Hypertensive Urgency (Do NOT send to ED):

• BP >180/120 mmHg WITHOUT any signs of acute organ damage 1
• Patient is otherwise stable, no acute symptoms beyond perhaps mild headache or anxiety 1
• These patients should NOT be referred to the emergency department 1

What to Do for Hypertensive Urgency in Your Office

For patients with BP >180/120 mmHg but no organ damage: 1, 2

• Repeat the blood pressure measurement in both arms after the patient has rested 1

• Perform targeted assessment for organ damage: 1, 3

  • Brief neurologic exam (mental status, focal deficits)
  • Cardiac exam (heart failure signs)
  • Fundoscopic exam if BP ≥180/110 mmHg 1
  • Consider basic labs: creatinine, urinalysis, ECG 1, 3

• Reinstitute or intensify oral antihypertensive therapy (not IV or sublingual) 1, 2

• Arrange close follow-up within 24-48 hours to reassess BP control 1, 4

• Avoid rapid BP reduction with short-acting agents like immediate-release nifedipine 2, 5

Common Pitfalls to Avoid

• Don't send stable patients with isolated BP elevation to the ED—this is the most common error. The absence of symptoms or organ damage means outpatient management is appropriate. 1
• Don't use sublingual nifedipine—it causes unpredictable, dangerous BP drops 2, 5, 6
• Don't assume the absolute BP number determines urgency—patients with chronic hypertension tolerate higher pressures; previously normotensive patients may have organ damage at lower levels 1, 2
• Don't overlook medication nonadherence—this is the most common cause of hypertensive urgency 1, 7

Practical Assessment Algorithm

Step 1: Confirm BP >180/120 mmHg with repeat measurement 1

Step 2: Ask about and examine for: 1, 3

• Severe headache, confusion, vision changes, weakness
• Chest pain or shortness of breath
• Back pain (dissection)
• Decreased urine output

Step 3: If ANY symptoms present → Send to ED immediately 1

Step 4: If NO symptoms → Perform fundoscopy (if trained), check basic labs if available, restart/intensify oral medications, arrange 24-48 hour follow-up 1, 2