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For further information, see CMDT Part 11-06: Hypertensive Urgencies & Emergencies

Key Features

Essentials of Diagnosis

  • Hypertensive crisis is typically defined as systolic blood pressure (BP) > 220 mm Hg or diastolic BP > 125 mm Hg

  • However, the development of acute end organ damage depends on

    • Rate of rise in BP

    • Magnitude of increase in BP

    • Presence of underlying conditions

General Considerations

  • Hypertensive urgency usually has systolic BP > 220 mm Hg or diastolic BP > 125 mm Hg without evidence of acute end-organ damage

  • Hypertensive emergency defined as acute hypertensive injury to heart, brain, retina, kidneys, aorta and/or eclampsia

  • Encephalopathy or nephropathy accompanying hypertensive retinopathy has historically been termed malignant hypertension, but the therapeutic approach is identical to that used in other hypertensive emergencies


  • Occurs in any age, gender, or racial/ethnic group

  • Usually occurs in people with preexisting hypertension

  • Often due to abrupt cessation of antihypertensive therapy

  • Also occurs in setting of acute kidney injury or use of high doses of sympathomimetics

Clinical Findings

Symptoms and Signs

  • Symptoms depend on the end organ involved

  • Headaches, irritability, confusion, and somnolence are signs of encephalopathy

  • Chest pain or dyspnea occurs with cardiopulmonary involvement

  • Back pain occurs with aortic dissection

  • Blurry or diminished vision occurs with retinal involvement

  • Cardiac examination may reveal low A2, an S4, or a murmur of aortic regurgitation

  • Papilledema is indicative of elevated intracranial pressure

  • Crackles on lung examination occur with heart failure

Differential Diagnosis

  • Any of the many causes of hypertension can lead to severe hypertension (see Hypertension, Chronic)

  • The underlying causes most likely to present in this way include

    • Poorly controlled or undiagnosed hypertension

    • Withdrawal from antihypertensive medications

    • Chronic kidney disease

    • Renal artery stenosis (atherosclerotic or fibromuscular dysplasia)

    • Sympathomimetic drug use

    • Scleroderma crisis

    • Pheochromocytoma


Laboratory Tests

  • Complete blood count (microangiopathic smear with thrombocytopenia due to platelet consumption)

  • Urinalysis

  • Serum creatinine, blood urea nitrogen, troponin, creatine kinase

  • ECG

  • Chest radiograph

  • Consider urine screen for cocaine

Diagnostic Procedures

  • If CNS symptoms, head CT to rule out bleed/infarct

  • If chest pain, ECG (to rule out coronary syndrome), chest radiograph (thoracic aortic dissection)

  • If kidney dysfunction, renal ultrasound to rule out obstruction or chronic kidney disease



Hypertensive urgency

  • Goal is to relieve symptoms and bring BP to reasonable level within 24–48 hours, aiming for gradual attainment of optimal control over several weeks

  • Effective oral agents are clonidine, captopril, and slow-release nifedipine

  • Avoid beta-blockers if cocaine use

  • Avoid angiotensin-converting enzyme (ACE) inhibitors if renal artery stenosis suspected


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