What is the difference between chronic hypertension, hypertensive urgency, and hypertensive emergency (crisis)?

Hypertensive Emergency vs. Urgency vs. Chronic Hypertension

Core Distinction: Presence of Target Organ Damage

The critical difference between hypertensive emergency and urgency is the presence or absence of acute target organ damage—not the absolute blood pressure number. 1, 2

Hypertensive Emergency

• Blood pressure >180/120 mmHg WITH acute target organ damage 1, 2
• Requires immediate ICU admission with continuous arterial line monitoring 1, 2
• Demands IV antihypertensive therapy 1, 2
• Untreated 1-year mortality exceeds 79% with median survival of only 10.4 months 1

Hypertensive Urgency

• Blood pressure >180/120 mmHg WITHOUT acute target organ damage 1, 2
• Managed with oral medications as outpatient 1, 2
• No hospital admission required 1, 2
• Blood pressure reduced gradually over 24-48 hours 1, 3

Chronic Hypertension

• Persistently elevated blood pressure without acute crisis
• Managed with scheduled oral medications
• Patients with chronic hypertension tolerate higher pressures than previously normotensive individuals due to altered autoregulation 1, 3

Rapid Assessment for Target Organ Damage

You must actively exclude target organ damage through focused evaluation—never assume absence of symptoms equals absence of organ injury. 1

Neurologic Damage

• Altered mental status, seizures, coma (hypertensive encephalopathy) 1, 2
• Severe headache with vomiting 1, 2
• Visual disturbances or cortical blindness 1
• Focal neurologic deficits suggesting stroke 1, 2
• Intracranial hemorrhage 1, 2

Cardiac Damage

• Chest pain suggesting acute myocardial infarction or unstable angina 1, 2
• Dyspnea with pulmonary edema (acute left ventricular failure) 1, 2
• Signs of cardiogenic shock 1

Vascular Damage

• Sudden severe chest or back pain radiating posteriorly (aortic dissection) 1, 2

Renal Damage

• Acute rise in serum creatinine or oliguria (acute kidney injury) 1, 2
• New proteinuria or abnormal urine sediment 1
• Thrombocytopenia with elevated LDH and low haptoglobin (thrombotic microangiopathy) 1

Ophthalmologic Damage (Malignant Hypertension)

• Bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) on fundoscopy 1, 2
• Isolated subconjunctival hemorrhage is NOT acute target organ damage 1

Obstetric Damage

• Severe preeclampsia or eclampsia 1, 2

Management Algorithm

IF Target Organ Damage Present (Emergency):

1. Immediate ICU Admission 1, 2

• Continuous arterial line blood pressure monitoring (Class I recommendation) 1

2. Blood Pressure Reduction Targets 1, 2

For patients WITHOUT compelling conditions:

• First hour: Reduce mean arterial pressure by 20-25% (or systolic ≤25%) 1, 2
• Hours 2-6: Lower to ≤160/100 mmHg if stable 1, 2
• Hours 24-48: Gradually normalize 1, 2
• Never drop systolic >70 mmHg to prevent cerebral, renal, or coronary ischemia 1, 3

For patients WITH compelling conditions:

• Aortic dissection: SBP <120 mmHg within 20 minutes 1
• Severe preeclampsia/eclampsia or pheochromocytoma: SBP <140 mmHg within first hour 1
• Acute coronary syndrome or pulmonary edema: SBP <140 mmHg immediately 1

3. First-Line IV Medications 1, 2, 3

Medication	Dose	Preferred Scenarios	Contraindications
Nicardipine (preferred for most)	Start 5 mg/h, increase by 2.5 mg/h every 15 min (max 15 mg/h)	Most emergencies except acute heart failure; preserves cerebral blood flow	Acute heart failure
Labetalol	10-20 mg IV bolus over 1-2 min, repeat/double every 10 min (max 300 mg) OR infusion 2-8 mg/min	Aortic dissection, eclampsia, malignant hypertension with renal involvement	Reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure
Clevidipine	1-2 mg/h, double every 90 sec until near target (max 32 mg/h)	Rapid titration needed	Soy/egg allergy

IF NO Target Organ Damage (Urgency):

1. Outpatient Management 1, 2

• No hospital admission required 1, 2
• No IV medications 1, 2

2. Blood Pressure Reduction Strategy 1, 3

• Gradual reduction to <160/100 mmHg over 24-48 hours 1, 3
• Then aim for <130/80 mmHg over subsequent weeks 1, 3
• Avoid rapid lowering—can cause cerebral, renal, or coronary ischemia 1, 3

3. Preferred Oral Agents 1

• Extended-release nifedipine 30-60 mg PO 1
• Captopril 12.5-25 mg PO (caution in volume depletion) 1
• Labetalol 200-400 mg PO (avoid in reactive airway disease, heart block, bradycardia) 1

4. Follow-Up 1, 2

• Outpatient visit within 2-4 weeks 1, 2
• Monthly visits until target BP achieved 1

Critical Pitfalls to Avoid

• Do not admit patients with severe hypertension who lack acute target organ damage 1
• Do not use IV medications for hypertensive urgency 1, 2
• Never use immediate-release nifedipine—causes unpredictable precipitous drops, stroke, and death 1, 3
• Do not rapidly lower BP in urgency—risk of ischemic complications 1, 3
• Do not acutely normalize BP in chronic hypertensives—altered autoregulation predisposes to ischemia 1, 3
• Do not treat the BP number alone—many patients with acute pain have transient elevations that resolve when underlying condition is treated 1
• Up to one-third of patients with diastolic >95 mmHg normalize before follow-up; aggressive reduction may be harmful 1

Post-Stabilization Considerations

• Screen for secondary causes—20-40% of malignant hypertension cases have identifiable etiologies (renal artery stenosis, pheochromocytoma, primary aldosteronism, renal parenchymal disease) 1
• Medication non-adherence is the most common trigger for hypertensive emergencies 1
• Patients with prior emergency remain at markedly increased cardiovascular and renal risk 1