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The Best in FOAM Education

  • Sara Rosenzweig, MD

Hypertensive Emergencies


  • Severe HTN typically defined as SBP > 180, DBP > 110, and/or MAP >135

  • MUST be associated with end organ damage

    • Stroke

    • Hypertensive encephalopathy

    • CRAO / Retinal hemorrhage

    • ACS

    • SCAPE / heart failure

    • AKI

  • Has significant morbidity and mortality

  • ***If no end organ damage present: HTN Urgency, hypertensive crisis, malignant HTN



  • Chemistry, CBC​

  • UA! To look for proteinuria, RBCs​

  • Trop​

  • EKG ​

  • CXR​

  • +/- CTH based on chief complaint, symptoms

Evidence for Management:

  • AHA/ACC (American Heart Association and American College of Cardiology) and the ESC (European Society of Cardiology):

    • Reducing BP by maximum of 25% in the first hour

    • Then, 160/100-110 over the next 2-6hrs

    • Exceptions

      • Aortic Dissection

      • Pre-eclampsia/eclampsia

      • Pheochromocytoma crisis

  • Don't forget to ask:

    • HTN meds, compliance

    • New meds: cough/cold meds, illicit drugs (cocaine, meth), serotonergic meds

    • Recent pregnancy, post-partum status

    • Sodium intake

    • Alcohol use

  • When to use what:

    • HEART FAILURE: consider diuretics, BIPAP, nitro

    • ACUTE ISCHEMIC STROKE: lower BP to <185/110 prior to intervention; use nicardipine, clevidipine, or labetalol

    • STEMI: nitrates!, betablockers (metoprolol) ? Probably reduce long-term risk for all-cause and cardiovascular mortality but avoid steep drop in BP​

    • ICH: SBP <140 (but not <130); use nicardipine or labetalol

    • AORTIC DISSECTION: SBP <120, use esmolol; if contraindication to beta blockers, can use diltiazem or verapamil; can also use vasodilators

    • HTN ENCEPHALOPATHY: dec map BY 20-25%, use nicardipine or labetalol

    • Pre-eclampsia/eclampsia: goal <140/90; use IV labetalol, hydralazine, or oral nifedipine

      • Mg loading dose of 4-6g IV over 20-30 min, then 1-2g/hr

    • AKI: dec ABP or MAP by 25%; use nicardipine, labetalol, clevidipine

  • BP comes down and you decide to send them home; are you sending them home with Rx?

    • Recent studies say no if no end organ damage ​

    • Rapid follow up is appropriate

Extra Pearls

  • Consider using MAP instead of only SBP/DBP​

  • If HTN emergency, use short acting IV anti HTN meds that allow for titration


Sara Rosenzweig, MD


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