• Hypertensive emergency is defined as BP >180/120 mm Hg with end-organ dysfunction.

  • Hypertensive urgency is defined as severe BP elevation without evidence of end-organ dysfunction.

Also called 

  • Hypertensive crisis

  • Malignant hypertension

ICD-9 codes

  • 401.0 malignant essential hypertension
  • 405.0 malignant secondary hypertension

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  • 1%-2% of patients with hypertension

  • More common in 

    — Elderly

    — Blacks

    — Men


  • New onset or complication of essential or secondary hypertension

    — Medication nonadherence

    — Use of monoamine oxidase inhibitor

    — Recreational drug use

    — Acute postoperative hypertension

Risk factors 

  • Ineffective outpatient BP control

  • Patient noncompliance with hypertension treatment

  • Lack of primary-care provider


  • End-organ damage may include

    — Encephalopathy

    — Intracerebral hemorrhage

    — Acute myocardial infarction

    — Unstable angina

    — Acute heart failure

    — Pulmonary edema

    — Dissecting aortic aneurysm

    — Acute renal failure

    — Preeclampsia/eclampsia

  • Hypotension may be a complication of aggressive treatment.


  • Patient may complain of

    — Chest pain 

    — Dyspnea 

    — Neurologic deficit 

    — Faintness 

    — Paresthesia 

    — Headache 

    — Vertigo 

    — Vomiting

    — Agitation

    — Epistaxis 

  • Most patients have persistently elevated BP for years before presenting with hypertensive emergency.

  • Review medications, adherence, and time from last dose

  • Ask about recreational drug use (e.g., amphetamines, cocaine, phencyclidine [PCP]).

Physical Exam

  • Confirm BP on both arms using a properly sized BP cuff.

  • Check pulses in all extremities.

  • Perform physical exam to evaluate for end-organ damage and to differentiate between hypertensive emergency and hypertensive urgency (no end-organ dysfunction).

    — Funduscopic exam (assess for arteriolar changes, hemorrhages, exudates, papilledema)

    — Cardiac exam (assess for murmurs and gallops)

    — Lung exam (assess for pulmonary edema)

    — Abdominal exam (assess for bruits, aortic aneurysm)

    — Neurologic exam (check mental status, lateralizing signs may suggest vascular event) 

Making the diagnosis

  • Hypertensive emergency—BP >180/120 mm Hg with evidence of end organ dysfunction 

  • Hypertensive urgency—severe BP elevation without evidence of end-organ dysfunction

Rule out

  • Subarachnoid hemorrhage—consider in patients with sudden onset of severe headache

  • Stroke—consider if focal neurologic findings, especially lateralizing signs

Testing to consider

  • Blood chemistries (electrolytes, blood urea nitrogen, creatinine)

  • Complete blood count

  • Urinalysis

  • Electrocardiogram

  • Consider cardiac biomarkers if cardiac ischemia suspected

  • Consider toxicology screen

  • Imaging based on clinical picture for specific conditions (e.g. chest x-ray, if dyspnea or chest pain)


  • Hypertensive urgency (no evidence of end organ damage)

    — Observe for several hours following administration of antihypertensives 

    — Medication options include 

    • Nicardipine 5 mg/hour orally, should be increased by 2 mg/hour every 15 minutes, maximum dose 15 mg/hour 

    • Captopril 25 mg orally two to three times daily 

    • Clonidine: Adults—initial dose 0.1-0.2 mg orally, then 
0.05-0.2 mg every hour up to total dose of 
0.5-0.7 mg as needed; Children aged 1-17 years—initial dose 0.05-
0.1 mg orally, repeat up to maximum 0.8 mg

    • Labetalol dose options include: initial dose 20-80 mg IV, then additional 40-
80 mg dose (range 20-80 mg) at 10-minute intervals until desired BP achieved; initial dose 0.5-2 mg IV infusion, adjust as required; initial dose 200 mg oral, then additional 200-
400 mg dose after six to 12 hours as needed
  • Hypertensive emergency (end-organ damage)

    • Admit to intensive care unit and treat with IV antihypertensives.

    • Continuous BP monitoring (consider intra-arterial blood pressure monitoring)

    • Give IV saline if volume depleted. 

    • In most cases, lower diastolic pressure by 10%-15% over the first hour.

    • Choosing BP lowering medications and BP goal depends on target organ with dysfunction.

— Acute aortic dissection

  • Lower systolic pressure to <120 mm Hg rapidly (i.e., five to 10 minutes)

  • Options include beta blockers (esmolol [Brevibloc], metoprolol [Lopressor, Toprol]) and vasodilators (nicardipine [Cardene], nitroprusside, fenoldopam [Corlopam])

— Ischemic Stroke

  • For thrombolysis candidates
    • IV therapy is indicated for patients if systolic pressure is >185 mm Hg or diastolic pressure is >110 mm Hg.

    • BP should be maintained at <180/105 mm Hg 
for at least first 24 hours after thrombolysis.

    • Options include labetalol [Normodyne, Trandate], nicardipine, or nitroglycerin topical ointment.

  • For patients not able to have thrombolysis

    • Lowering BP (by 15%-25% in first 24 hours) is indicated if systolic pressure is >220 mm Hg or diastolic pressure is >120 mm Hg.

    • Options include labetalol, nicardipine.

— Acute hemorrhagic stroke

  • The goal of BP lowering depends on how elevated BP is and whether there is elevated intracranial pressure.
  • Options include enalaprilat [Vasotec], esmolol, hydralazine [Apresoline], labetalol, nitroglycerin, nicardipine.

— Hypertensive encephalopathy

  • Treat promptly, as delay can lead to seizures and neurologic deficits.

  • Lower mean arterial pressure by 20%-25% in the first hour

  • Targets are then systolic pressure of 160 mm Hg and diastolic pressure of 90-100 mm Hg.

  • If patient is tolerating treatment, gradually lower BP further over next 24 hours.

  • Options include IV labetalol or nicardipine.

  • Avoid nitroprusside, which might increase intracranial pressure. 

— Acute myocardial ischemia

  • Nitroglycerin drug of choice

  • Treatment alternatives include labetalol, esmolol, clevidipine [Cleviprex], nicardipine.

— Acute pulmonary edema

  • Options include nitroglycerin, nitroprusside, 
furosemide [Delone, Furocot, Lasix, Lo-Aqua].

— Acute renal failure

  • Options include nicardipine, fenoldopam, clevidipine.

— Preeclampsia/eclampsia

  • Initiate antihypertensive treatment when diastolic blood pressure is ≥105-110 mm Hg.

  • Maintain systolic BP 130-160 mm Hg and diastolic BP 80-110 mm Hg.

  • Options include labetalol, hydralazine, nifedipine.

  • Treatment usually also includes magnesium sulfate for seizure prevention.

— Sympathetic crisis (e.g., cocaine overdose)

  • Avoid beta-blockers, which might lead to increased BP.

  • Options include nicardipine, diltiazem, phentolamine, verapamil [Calan, Covera, Isoptin, Verelan].

  • Consider treatment with benzodiazepine in addition to antihypertensive medication.

— Acute postoperative hypertension

  • Usually starts less than two hours after surgery and lasts six hours or more.

  • No consensus regarding treatment threshold (except cardiac surgery patients where treatment recommended for BP >140/90 mm Hg or MAP 
≥105 mm Hg)

  • Options include esmolol, nicardipine, clevidipine, labetalol, nitroprusside.

— Transition to oral therapy as soon as possible after BP stabilization

Brian Randall, MD, is a clinical editor for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and Assistant Clinical Professor of Family Medicine at Tufts University School of Medicine.