Hypertensive Crisis

• Organ damage (encephalopathy, APE, ACS, AKI, retinopathy) = emergency; no damage = "severe hypertension" (formerly urgency) → oral agents; no intermittent IV boluses without organ damage.
• IV nicardipine/labetalol/clevidipine; cut MAP ≤20–25% in 1–2 h, then gradually over 24–48 h.
• Exceptions: dissection (SBP <120 in 20 min), ischemic stroke (permissive), eclampsia (Mg + labetalol).
• Sublingual nifedipine contraindicated: precipitous drops.

General Strategy for Hypertensive Emergencies

• Severe HTN, usually >180/120
• Goals: targeted, brief, often simultaneous history and physical — 1) identify patient characteristics raising HTN emergency risk; 2) identify signs/symptoms of target organ damage (TOD)
• History — HPI, TOD symptoms: cardiac (chest pain, SOB/DOE, orthopnea) · CNS (MS changes, headache, weakness, vision change) · renal (hematuria, ↓urine output) · medications: anti-HTN meds (dose changes, compliance), MAO inhibitors, OTCs, herbal remedies · PMH: Hx of HTN; Hx of CNS, cardiac/aortic, or renal disease; Ob/Gyn Hx · social/family: cocaine/amphetamine use, family Hx of cardiac/aortic disease
• Exam — vitals: BP in both arms and legs, ↑HR, ↓SaO₂ · general: agitation, anxiety, restlessness · CV: S3, S4, diastolic murmur of AI, elevated JVP, peripheral edema, arterial bruits, pulse deficits · fundoscopic: hemorrhages, exudates, papilledema · pulm: crackles/rales · neuro: mental status changes, focal neurologic deficits
• Diagnostic studies: CBC · electrolytes · BUN/creatinine · glucose · U/A (RBCs, casts) · cardiac enzymes · CXR (wide mediastinum, pulmonary edema) · ECG (ST/T wave changes, Q waves, LVH). When available, obtain prior ECG/CXR/labs for baseline and to confirm dynamic changes
• Acute, ongoing TOD evident?
• HYPERTENSIVE EMERGENCY — general goals: halt TOD progression; avoid organ hypoperfusion during treatment
• Key points: start parenteral therapy immediately — further testing must not delay treatment · ICU admission with intra-arterial BP monitoring preferred
• Generally lower MAP by no more than 20% within minutes to an hour; over the next 2–6 hours target roughly 160/110 mm Hg if the initial reduction was well tolerated
• Choose parenteral agents by the specific hypertensive syndrome · plan the oral regimen from medical comorbidities and home meds · typically wean parenteral agents and start oral therapy once BP has been controlled 12–24 hours and autoregulation is reestablished · after acute treatment begins, consider a secondary hypertension workup in appropriate patients
• Go to syndrome-specific management goals
• HYPERTENSIVE URGENCY — start oral antihypertensive therapy based on medical comorbidities and home meds · set monitoring level by clinical substrate and availability of close outpatient follow-up
• Most patients are manageable as outpatients, targeting 20% MAP reduction in 1–2 days with further reduction to ambulatory goals over weeks to months · arrange outpatient follow-up within 48–72 hours to ensure compliance and stress long-term BP control to lower CV risk