Hypertensive emergency — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 64-year-old man, not pregnant and with no stroke, presents with breathlessness. BP is 214/126 mm Hg, and examination and chest imaging show acute pulmonary oedema. He has no aortic dissection and no acute coronary syndrome.^[2]

1. Define hypertensive emergency according to the 2024 ESC guideline and the 2025 AHA/ACC guideline. (2)^[1][2]
2. Where does AHA/ACC 2025 recommend he is managed, for what purposes, and with what class of recommendation? (2)^[2]
3. Which intravenous drugs does AHA/ACC 2025 Table 27 (IV drugs for treating hypertensive emergencies in patients with selected comorbidities) list as preferred for a hypertensive emergency with acute pulmonary oedema, and which drug class does it contraindicate? (2)^[2]
4. Explain, with reference to cerebral autoregulation, why rapid correction of BP to the normal range may be harmful in longstanding hypertension. (2)^[7][2]
5. What does ESC 2024 say about his prognosis and follow-up after the emergency? (2)^[1]

Model answers — SAQ 1

1. ESC 2024: BP of 180/110 mmHg or more associated with acute hypertension-mediated organ damage (HMOD), often in the presence of symptoms (1 mark).^[1] AHA/ACC 2025: severe elevation in BP (above 180/120 mm Hg) associated with evidence of acute target organ damage (1 mark).^[2]
2. In nonpregnant, nonstroke adults with a hypertensive emergency (BP above 180 and/or above 120 mm Hg and evidence of acute target organ damage), AHA/ACC 2025 recommends admission to an intensive care unit (1 mark) for continuous monitoring of BP and target organ damage and for consideration of parenteral administration of appropriate therapy, with COR 1, LOE B-NR (1 mark).^[2]
3. Preferred: clevidipine, nitroglycerin and nitroprusside, listed in alphabetical order rather than order of preference (1 mark for any two).^[2] In a hypertensive emergency with acute pulmonary oedema, Table 27 states that beta blockers are contraindicated (1 mark).^[2]
4. Chronic hypertension shifts the lower and upper limits of cerebral blood flow autoregulation towards higher pressure, and acute BP reduction lowers cerebral blood flow only if pressure is taken below the lower limit (1 mark).^[7] AHA/ACC 2025 states that rapid correction of BP to the normal range in patients with longstanding hypertension may result in vital organ hypoperfusion due to loss of autoregulation (1 mark).^[2]
5. ESC 2024 states that survival after hypertensive emergencies has improved over the past few decades, but these patients remain at high risk (1 mark).^[1] ESC 2024 states that these patients should be screened for secondary hypertension (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 29-year-old woman at 35 weeks of gestation has headache and new proteinuria. BP is 172/114 mmHg, confirmed on repeat measurement 10 minutes later. Pre-eclampsia is diagnosed.^[1]

1. State the BP threshold at which each guideline treats BP in pregnancy as a possible emergency or as needing urgent treatment: ESC 2024 Recommendation Table 22 and AHA/ACC 2025 Section 5.5. Include class or COR. (2)^[1][2]
2. According to AHA/ACC 2025, to what BP and over what time should her BP be lowered? (2)^[2]
3. List the three ESC 2024 Recommendation Table 33 rows, with their class and level. (3)^[1]
4. Give the ESC 2024 magnesium sulfate regimen and one drug interaction caution. (2)^[1]
5. Name two drugs or drug classes that AHA/ACC 2025 Table 27 (IV drugs for treating hypertensive emergencies in patients with selected comorbidities) lists as contraindicated in eclampsia or preeclampsia. (1)^[2]

Model answers — SAQ 2

1. ESC 2024: systolic BP of 160 mmHg or more or diastolic BP of 110 mmHg or more in pregnancy can indicate an emergency, and immediate hospitalisation should be considered (Class IIa, Level C) (1 mark).^[1] AHA/ACC 2025: pregnant individuals with SBP of 160 mm Hg or more or DBP of 110 mm Hg or more, confirmed on repeat measurement within 15 minutes, should receive antihypertensive medication (COR 1, LOE B-R) (1 mark).^[2]
2. AHA/ACC 2025 recommends lowering BP to below 160/110 mm Hg (1 mark) within 30 to 60 minutes, to prevent adverse events (1 mark).^[2]
3. In pre-eclampsia or eclampsia with hypertensive crisis, drug treatment with i.v. labetalol or nicardipine and magnesium is recommended (Class I, Level C) (1 mark).^[1] In pre-eclampsia or eclampsia associated with pulmonary oedema, nitroglycerin given as an i.v. infusion is recommended (Class I, Level C) (1 mark).^[1] In severe hypertension in pregnancy, drug treatment with i.v. labetalol, oral methyldopa or oral nifedipine is recommended, and i.v. hydralazine is a second-line option (Class I, Level C) (1 mark).^[1]
4. ESC 2024 text: magnesium sulfate (4 g i.v. over 5 min, then 1 g/h i.v.; or 5 g intramuscularly into each buttock, then 5 g i.m. every 4 h) is recommended for eclampsia treatment and for women with pre-eclampsia who have severe hypertension and proteinuria or hypertension and neurological symptoms or signs (1 mark).^[1] There is a risk of hypotension when magnesium is given concomitantly with nifedipine (1 mark).^[1]
5. Any two of ACE inhibitors, ARBs, renin inhibitors and nitroprusside, which AHA/ACC 2025 Table 27 (IV drugs for treating hypertensive emergencies in patients with selected comorbidities) lists as contraindicated in eclampsia or preeclampsia (1 mark).^[2]