EM · Hypertensive emergency
Hypertensive emergency
Also known as Hypertensive crisis · Malignant hypertension · Accelerated hypertension
Severe blood-pressure elevation with acute end-organ damage — the distinction between a hypertensive emergency and urgency (end-organ damage, not the number), the affected organs (brain, heart, kidney, retina, pregnancy, aorta), the rationale for controlled lowering (the shifted cerebral autoregulation curve), the titratable intravenous agents with doses and per-scenario targets, the magnesium-for-eclampsia and phaeochromocytoma-alpha-first rules, and the agents to avoid. ACEM-primary, globally tagged.
Checked against its sources on 12 Sept 2026
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Red flags
- A hypertensive emergency is defined by acute end-organ damage, not by the absolute blood pressure — a patient at 220/130 with no organ damage has urgency, not an emergency
- Lower the pressure gradually — about 10 to 20 per cent in the first hour — because chronic hypertensives have a shifted cerebral autoregulation curve and rapid lowering causes cerebral and coronary hypoperfusion
- Never use sublingual nifedipine — its onset is unpredictable and causes precipitant cerebral hypoperfusion
- In suspected phaeochromocytoma crisis, give an alpha-blocker first — a beta-blocker first leaves unopposed alpha vasoconstriction and worsens the hypertension
- In aortic dissection the target is aggressive (systolic 100 to 120) with a beta-blocker first — distinct from every other hypertensive emergency
- Severe hypertension with headache, visual disturbance and clonus in pregnancy is pre-eclampsia/eclampsia — give magnesium sulphate and plan delivery
Meet the patient
A 52-year-old man with untreated hypertension is brought in confused, breathless, with a three-day headache and blurred vision. Blood pressure is 226 over 144 in both arms, heart rate 108, saturations 93 per cent. Fundoscopy shows papilloedema and flame haemorrhages. He has bibasal crackles. The registrar reaches for sublingual nifedipine.[1]
Three questions decide the next hour, and they are the three that decide every hypertensive emergency: what is the threatened organ? (brain, heart, kidney, retina, pregnancy, aorta — each dictates its own agent), how fast can I safely lower it? (gradually, 10 to 20 per cent in the first hour, because chronic hypertensives have a shifted autoregulation curve), and which agent fits this organ? The registrar's sublingual nifedipine answers none of them.[1]
References7ShowHide
- [1]Kreutz R, Brunström M, Burnier M, et al. 2024 European Society of Hypertension clinical practice guidelines for the management of arterial hypertension. Eur J Intern Med, 2024.PMID 38914505
- [2]Shanmugalingam R, Barrett HL, Beech A, et al. A summary of the 2023 Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) hypertension in pregnancy guideline. Med J Aust, 2024.PMID 38763516
- [3]Cífková R, Johnson MR, Kahan T, et al. Peripartum management of hypertension: a position paper of the ESC Council on Hypertension and the European Society of Hypertension. Eur Heart J Cardiovasc Pharmacother, 2020.PMID 31841131
- [4]Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med, 2016.PMID 27276234
- [5]Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med, 2013.PMID 23713578
- [6]Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014.PMID 25173340
- [7]Marik PE, Varon J Hypertensive crises: challenges and management. Chest, 2007.PMID 17565029