From the Guidelines
A hypertensive emergency is defined as a blood pressure reading of >200/120 mmHg with evidence of acute target organ damage, as stated in the 2020 international society of hypertension global hypertension practice guidelines 1. This severe elevation requires immediate medical attention and hospitalization for rapid but controlled blood pressure reduction to prevent life-threatening complications. Common presentations of hypertensive emergencies include:
- Malignant hypertension: Severe BP elevation (commonly >200/120 mm Hg) associated with advanced bilateral retinopathy (hemorrhages, cotton wool spots, papilledema) 1.
- Hypertensive encephalopathy: Severe BP elevation associated with lethargy, seizures, cortical blindness and coma in the absence of other explanations 1.
- Hypertensive thrombotic microangiopathy: Severe BP elevation associated with hemolysis and thrombocytopenia in the absence of other causes and improvement with BP-lowering therapy 1. Other presentations of hypertensive emergencies include severe BP elevation associated with cerebral hemorrhage, acute stroke, acute coronary syndrome, cardiogenic pulmonary edema, aortic aneurysm/dissection, and severe preeclampsia and eclampsia 1. The goal of treatment is to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and gradually to normal levels over the following 24-48 hours, as recommended by the 2019 esc council on hypertension position document on the management of hypertensive emergencies 1. Too rapid reduction can cause organ hypoperfusion. Patients experiencing symptoms such as severe headache, blurred vision, chest pain, shortness of breath, or neurological changes alongside severely elevated blood pressure should seek emergency care immediately. Hypertensive emergency differs from hypertensive urgency, which has the same blood pressure threshold but without acute organ damage and can often be managed in an outpatient setting. The choice of antihypertensive treatment is predominantly determined by the type of organ damage, as stated in the 2020 international society of hypertension global hypertension practice guidelines 1. Intravenous therapy is usually required, and common medications used for immediate treatment include intravenous labetalol, nicardipine, clevidipine, or nitroprusside 1.
From the Research
Definition of Hypertensive Emergency
A hypertensive emergency is defined as a condition where there is elevation of both systolic and diastolic blood pressure with the presence of acute target organ disease 2.
Blood Pressure Reading for Hypertensive Emergency
The blood pressure reading for a hypertensive emergency is typically defined as a systolic blood pressure > 180 mm Hg or a diastolic blood pressure > 120 mm Hg 3, 4, 5.
Key Characteristics
Key characteristics of a hypertensive emergency include:
- Elevation of both systolic and diastolic blood pressure
- Presence of acute target organ disease
- Requires immediate reduction of blood pressure with a titratable short-acting intravenous antihypertensive agent
- Patients are best treated in an intensive care unit (ICU) with close monitoring of blood pressure and end-organ function 3, 4, 5.
Treatment Options
Treatment options for hypertensive emergencies include:
- Rapid-acting intravenous antihypertensive agents such as labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside
- Newer agents such as clevidipine may have advantages over traditional agents 3, 4, 5
- The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 6.