Hypertension
at the bedside
- full vitals; cardiac monitor if symptomatic
- confirm → correct cuff, arm at heart level, patient rested; repeat and compare with baseline; both arms if severe or dissection suspected
- ask about chest pain, dyspnea, neurological deficit, visual change, severe headache
- severe hypertension → BP >180/120 without new target-organ damage: treat on the ward, orally
- hypertensive emergency → BP >180/120 with new or worsening target-organ damage: escalate
chronic BP categories
- normal <120/80 · elevated 120–129 / <80 · stage 1 130–139 / 80–89 · stage 2 ≥140/90
- one inpatient reading does not diagnose chronic hypertension
escalate now if: BP ≥ 180/120 with any of
- new neurological deficit, confusion or seizure → CT first: ischemic stroke or hemorrhage
- tearing chest or back pain → aortic dissection
- chest pain or ischemic ECG changes → ACS → emergency treatment
- dyspnea + crackles → pulmonary edema → emergency treatment
- decreasing urine output, rising creatinine, or new visual loss → emergency treatment
- papilledema → hypertensive encephalopathy → targets
- pregnant or postpartum → urgent obstetric review
focused check
- symptoms by organ
- neuro → headache, confusion, visual change, focal deficit, seizure
- cardiopulmonary → chest pain, dyspnea, orthopnea, palpitations
- renal → low urine output, hematuria
- triggers → pain, anxiety, urinary retention, hypoxia, fluid overload
- drug chart → missed or held antihypertensives; NSAIDs, steroids, decongestants, stimulants, calcineurin inhibitors, erythropoietin; clonidine or alcohol withdrawal
- examine → neurological if altered or focal; volume status; pulses in both arms; fundoscopy when possible
send now
- ECG; troponin if chest pain
- RFT, electrolytes; urinalysis
- CXR if dyspnea; CT head if neurological deficit, confusion or severe headache
- pregnancy test if relevant
treat
severe hypertension without acute target-organ damage
- no IV agents → do not lower rapidly
- treat pain, anxiety, urinary retention, hypoxia
- restart held antihypertensives or adjust the oral regimen → oral antihypertensives and starting doses
- repeat BP and trend it; watch symptoms, urine output and creatinine
suspected hypertensive emergency
- early involvement of senior and ICU
- continuous monitoring, preferably an arterial line
- titratable IV antihypertensive chosen by the organ involved (table below)
BP target, most hypertensive emergencies
- first hour → lower by no more than ~25%
- next 2–6 h → toward 160/100–110
- then to normal over 24–48 h, unless a condition-specific target applies
condition-specific targets
- ischemic stroke, no thrombolysis → treat only if ≥220/120 or another emergency indication; lower by about 15% in the first 24 h
- before thrombolysis → <185/110; after → keep <180/105 for 24 h
- aortic dissection → IV beta-blocker first to HR <60, then SBP 100–120 as fast as safely possible; cardiothoracic and ICU now
- intracerebral hemorrhage → SBP 150–220 on arrival: lower to 140 and hold at 130–150, smoothly, never below 130; neurosurgery and ICU early
IV medication selection
| drug · for | order |
|---|---|
| labetalol · most emergencies | 10–20 mg IV over 2 min, repeat or double every 10 min (20–80 mg), max 300 mg |
| esmolol · aortic dissection, with a vasodilator | 500 mcg/kg IV over 1 min, then 50 mcg/kg/min, up to 300 mcg/kg/min |
| GTN · ACS, pulmonary edema | 5 mcg/min IV, up by 5–10 mcg/min every 3–5 min, range 5–100 mcg/min |
| nitroprusside · refractory, ICU only | 0.3 mcg/kg/min IV, range 0.3–10 mcg/kg/min, arterial line |
- labetalol, esmolol → not in bradycardia, heart block, cardiogenic shock, decompensated HF; labetalol also not in asthma
- GTN → not after a PDE5 inhibitor, in hypotension, RV infarction or severe aortic stenosis
- nitroprusside → cyanide toxicity with prolonged or high doses, worse in renal failure
- hydralazine → avoid outside pregnancy, response is unpredictable and prolonged
- oral agents → ACEi / ARB not in pregnancy, angioedema history, bilateral renal artery stenosis or single kidney, hyperkalemia (also aldosterone antagonists); verapamil / diltiazem not in 2°/3° heart block; thiazides not in hyponatremia
- hand over → BP trend, drugs given, target for the next 6 h, escalation trigger
evidence
| source | type |
|---|---|
| 2025 AHA/ACC hypertension guideline | international guideline |
| 2024 AHA acute-care BP statement | international guideline |
| 2026 AHA/ASA acute ischemic stroke guideline | international guideline |
| 2022 AHA/ASA spontaneous intracerebral hemorrhage guideline | international guideline |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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reviewed 17 Aug 2026updated Oct 2026file vital/blood-pressure-hypertension