Hypertensive Emergency and Urgency Management

Key Definitions and Diagnosis

The presence or absence of acute target organ damage is the sole deciding factor that distinguishes hypertensive emergency from urgency, according to the American College of Cardiology 1, 2
Hypertensive emergency is defined as severely elevated blood pressure (>180/120 mmHg) with evidence of new or progressive acute target organ damage, requiring immediate intervention in an ICU setting with IV medications, as recommended by the American Heart Association 1, 2, 3
Hypertensive urgency is defined as severely elevated blood pressure (>180/120 mmHg) without acute target organ damage, and can be managed with oral medications and outpatient follow-up, according to the European Society of Cardiology 1, 2, 4

Acute target organ damage can occur in various organ systems, including the brain, heart, eyes, kidneys, and blood vessels, and must be systematically evaluated, as recommended by the American College of Cardiology 1, 3
Neurologic damage can manifest as hypertensive encephalopathy, acute ischemic stroke, or intracranial hemorrhage, according to the European Heart Journal 1, 4
Cardiac damage can manifest as acute myocardial infarction, unstable angina, or acute left ventricular failure with pulmonary edema, as recommended by the American Heart Association 1, 3

For hypertensive emergency, admit to ICU immediately with continuous arterial blood pressure monitoring and IV titratable agents, and target blood pressure reduction, as recommended by the American College of Cardiology 1, 2, 3
For hypertensive urgency, reinstitute or intensify oral antihypertensive therapy, and arrange outpatient follow-up within 2-4 weeks, according to the European Society of Cardiology 1, 2

Do not treat blood pressure alone without assessing for true target organ damage, as recommended by the American College of Cardiology 1
Avoid excessive acute blood pressure drops (>70 mmHg systolic), which can precipitate cerebral, renal, or coronary ischemia, according to the European Heart Journal 1, 4
Never use immediate-release nifedipine, which can cause unpredictable precipitous blood pressure drops and reflex tachycardia, as warned by the American Heart Association 1, 3