What is the difference between a hypertensive crisis and hypertensive urgency?

Hypertensive Crisis vs. Hypertensive Urgency: Key Distinctions

The critical difference is the presence or absence of acute target organ damage—not the blood pressure number itself. Both conditions involve severe blood pressure elevation (>180/120 mmHg), but hypertensive emergency (the more severe form of hypertensive crisis) requires evidence of new or worsening target organ damage, while hypertensive urgency does not 1, 2, 3.

Defining Characteristics

Hypertensive Emergency (Hypertensive Crisis)

• Blood pressure >180/120 mmHg WITH acute target organ damage 1, 2, 3
• The rate of BP rise may be more important than the absolute number—patients with chronic hypertension often tolerate higher pressures than previously normotensive individuals 1, 2
• Untreated, carries a 1-year mortality rate >79% with median survival of only 10.4 months 1, 2
• Requires immediate ICU admission (Class I recommendation, Level B-NR) 1, 2, 3

Target organ damage includes:

• Neurologic: Hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke 1, 2, 3
• Cardiac: Acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina 1, 2, 3
• Vascular: Aortic dissection or aneurysm 1, 2, 3
• Renal: Acute kidney injury, thrombotic microangiopathy 1, 2
• Ophthalmologic: Malignant hypertension with retinal hemorrhages, cotton wool spots, papilledema 2, 3
• Obstetric: Severe preeclampsia or eclampsia 1, 3

Hypertensive Urgency

• Blood pressure >180/120 mmHg WITHOUT acute target organ damage 1, 2, 3
• Patients are otherwise stable with no acute or impending change in target organ function 1
• Many have withdrawn from or are noncompliant with antihypertensive therapy 1
• Does NOT require emergency department referral, immediate BP reduction, or hospitalization 1, 3

Management Approach: The Critical Divergence

For Hypertensive Emergency

Immediate ICU admission with continuous monitoring and IV therapy 1, 2, 3:

• First-line IV agents: Nicardipine, clevidipine, labetalol, or sodium nitroprusside (though nitroprusside should be avoided when possible due to toxicity) 1, 2, 4, 5
• BP reduction targets:
  • For compelling conditions (aortic dissection, severe preeclampsia/eclampsia): Reduce SBP to <140 mmHg within first hour, <120 mmHg for aortic dissection 1, 2
  • For non-compelling conditions: Reduce SBP by no more than 25% within first hour, then if stable to 160/100 mmHg over 2-6 hours, then cautiously to normal over 24-48 hours 1, 2, 3
• Avoid excessive drops >70 mmHg systolic—this can precipitate cerebral, renal, or coronary ischemia, especially in patients with chronic hypertension who have altered autoregulation 1, 2

For Hypertensive Urgency

Outpatient management with oral antihypertensives 1, 3:

• Reinstitute or intensify oral antihypertensive therapy 1, 3
• Gradual BP reduction over 24-48 hours 3
• Arrange follow-up within 2-4 weeks 2
• Target BP <130/80 mmHg (or <140/90 mmHg in elderly/frail patients) within 3 months 2
• No indication for emergency department referral or hospitalization 1

Common Pitfalls to Avoid

• Don't treat the BP number alone—many patients with acute pain or distress have transiently elevated BP that normalizes when the underlying condition is treated 2
• Don't use oral therapy for hypertensive emergencies—these require titratable IV agents 1, 4, 5
• Avoid immediate-release nifedipine, hydralazine, and nitroglycerin as first-line agents—they cause unpredictable BP drops and adverse effects 2, 4, 5, 6
• Don't normalize BP acutely in hypertensive emergency—patients with chronic hypertension cannot tolerate acute normalization due to altered cerebral autoregulation 1, 2
• Up to one-third of patients with diastolic BP >95 mmHg normalize before follow-up—rapid BP lowering in urgency may be harmful 2

Clinical Assessment Algorithm

1. Confirm BP >180/120 mmHg with repeat measurement 2
2. Assess for symptoms suggesting organ damage: Headache, visual changes, chest pain, dyspnea, neurological symptoms 2
3. Perform focused exam: Brief neurologic exam, cardiac assessment, fundoscopic exam 2
4. If target organ damage present: Hypertensive emergency → ICU admission + IV therapy 1, 2, 3
5. If NO target organ damage: Hypertensive urgency → Oral antihypertensives + outpatient follow-up 1, 3