Hypertension
ABCs
- ABCs, full vitals; cardiac monitor if symptomatic or severely elevated
- confirm the reading before treating it
- correct cuff size, arm supported at heart level, patient rested
- repeat; compare with baseline
- both arms if initial severe reading or suspected dissection
- do not treat an artefact or single unreliable reading
- screen for symptoms: chest pain, dyspnea, neurological deficit, visual change, severe headache
red flags
BP ≥ 180/120 → look for new target-organ damage
- symptoms prompt urgent assessment but do not alone establish hypertensive emergency
- new neurological deficit, confusion or seizure (encephalopathy, stroke)
- tearing chest or back pain → aortic dissection
- chest pain or ischemic ECG changes → ACS
- dyspnea + crackles → pulmonary edema
- decreasing urine output, rising creatinine
- new visual loss or papilledema
- pregnant or postpartum with severe hypertension → urgent obstetric review, follow obstetric emergency protocol
definitions
- chronic categories → normal <120/80 · elevated 120–129 / <80 · stage 1 130–139 / 80–89 · stage 2 ≥140/90
- severe hypertension → BP >180/120 without new or worsening acute target-organ damage
- hypertensive emergency → severe BP elevation with new or worsening acute target-organ damage
- do not diagnose chronic hypertension from one inpatient reading; confirm with repeated outpatient measurements
HPI & examination
- symptom review by organ
- neuro → headache, confusion, visual changes, focal deficits, seizures ± nausea/vomiting with raised ICP
- cardiopulmonary → chest pain, dyspnea, orthopnea, PND, pulmonary edema, palpitations
- renal → decreased urine output, hematuria
- contributing factors
- pain, anxiety, agitation
- urinary retention
- hypoxia
- volume status (overload vs depletion)
- review medication history: missed or held antihypertensives
- BP-raising drugs: NSAIDs, corticosteroids, decongestants, stimulants, cocaine / amphetamines, calcineurin inhibitors, erythropoietin; withdrawal (clonidine, alcohol)
- focused exam
- neurological if altered LOC or deficits
- cardiopulmonary: volume status, pulses both arms
- fundoscopy when possible
management
severe hypertension without acute target-organ damage
- do not lower rapidly with IV agents
- treat reversible contributors: pain, anxiety, urinary retention, hypoxia
- repeat and trend the BP
- review why antihypertensives were missed or held
- restart or adjust oral treatment when clinically appropriate
- monitor symptoms, urine output, renal function, overall trend
suspected hypertensive emergency
- urgent senior / ICU escalation: not managed alone on the ward
- continuous monitoring; consider arterial line
- titratable IV antihypertensive selected by organ involved: no single universal drug
BP target, most hypertensive emergencies
- reduce BP by no more than ~25% in the first hour
- then toward 160/100–110 over the next 2–6 hours
- then gradually over 24–48 h, unless a condition-specific target applies
condition-specific targets
- acute ischemic stroke, no reperfusion therapy → generally avoid BP lowering unless ≥220/120 or another emergency indication; if required, reduce cautiously (~15% in first 24 h)
- before IV thrombolysis → <185/110
- after thrombolysis → maintain <180/105 for 24 h (a maintenance ceiling, not a treatment-initiation threshold)
- aortic dissection → urgent heart-rate control (HR <60, IV beta-blocker first) plus SBP 100–120 as rapidly as safely achievable; immediate cardiothoracic / ICU escalation
- intracerebral hemorrhage → no universal number; follow condition-specific stroke guidance and local neuro protocol, avoid abrupt overcorrection
IV medication selection
choose by emergency syndrome and target organ: not a flat menu of equivalent options
| drug | best suited to | dose | important contraindications / cautions |
|---|---|---|---|
| labetalol | general first-line, most phenotypes | 20 mg IV over 2 min; may repeat 40–80 mg IV q10 min; max cumulative 300 mg | severe bradycardia; >1° AV block without pacing; cardiogenic shock; decompensated HF; asthma / active bronchospasm |
| esmolol | rapid β-blockade: aortic syndromes (with vasodilator), perioperative tachycardia-hypertension | 500 mcg/kg IV over 1 min, then 50 mcg/kg/min infusion; titrate up to 300 mcg/kg/min | sinus bradycardia; >1° heart block; cardiogenic shock; decompensated HF |
| glyceryl trinitrate (GTN) | ACS, acute pulmonary edema | start 5 mcg/min IV, titrate by 5–10 mcg/min q3–5 min (range 5–100 mcg/min) | recent PDE5-inhibitor or riociguat; hypotension / shock; preload-dependent states (RV infarction, severe aortic stenosis); may worsen HCM |
| nitroprusside | refractory hypertensive emergency, ICU setting | start 0.3 mcg/kg/min IV; titrate to effect (range 0.3–10 mcg/kg/min). Requires continuous BP monitoring | avoid prolonged / high-dose use: cyanide / thiocyanate toxicity risk, especially with renal dysfunction; contraindicated in compensatory hypertension (coarctation, AV shunting) |
hydralazine: generally avoided for routine (non-pregnancy) emergencies, response is unpredictable and prolonged
drug cautions
| condition | caution / avoid |
|---|---|
| angioedema history | avoid ACE inhibitors |
| active bronchospasm / severe reactive airways | non-selective beta blockers |
| active liver disease | methyldopa |
| pregnancy | avoid ACEi, ARB, renin inhibitors |
| significant 2°/3° heart block without pacing | beta blockers, non-DHP CCBs |
| severe bilateral renal artery stenosis, or solitary functioning kidney | ACEi / ARB |
| gout | diuretics (may precipitate flares, not absolute) |
| hyperkalemia | ACEi, ARB, aldosterone antagonists |
| hyponatremia | thiazide diuretics |
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 |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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Last clinically reviewed · 17 August 2026 · Last updated · August 2026