Hypertensive Crisis

Heart & Circulation · ICU Decoded chapter 21 · Locked — free with a referral

By Dr Javed Akhtar · Last reviewed 3 October 2026

Cited to ACC/AHA 2025; ESC/ESH.

Key points

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 SBP by no more than 25% in the first hour, to <160/100 over the next 2–6 h, then to SBP 130–140 over 24–48 h.
Exceptions: dissection (SBP <120 in 20 min), ischemic stroke (permissive), eclampsia (Mg + labetalol).
Sublingual nifedipine contraindicated: precipitous drops.

Investigations

First tests: Repeated BP and target-organ examination, 12-lead ECG, Sodium, potassium, bicarbonate, urea and creatinine, Urinalysis and microscopy.

Only if indicated: High-sensitivity cardiac troponin, Noncontrast CT head, CT angiography of the aorta, Pregnancy test.

Repeat monitoring: Sodium, potassium, bicarbonate, urea and creatinine.

Management pathways in this chapter

General Strategy for Hypertensive Emergencies

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The pathway step by step, with its decision points
Treatment orders with doses
Why and when to send each test

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