Management of Hypertensive Emergencies and Urgencies

Immediate Assessment and Diagnosis

The presence or absence of acute target organ damage is the sole determining factor for emergency referral, not the blood pressure number itself, according to the American College of Cardiology 1
Assess for target organ damage, including neurologic, cardiac, vascular, renal, and ophthalmologic damage, to determine the need for hospital admission 1, 2
The American Heart Association recommends assessing for symptoms such as altered mental status, confusion, or somnolence, as well as visual disturbances or vision loss, to determine the presence of target organ damage 1, 2

Reduce mean arterial pressure by 20-25% within the first hour, then if stable reduce to 160/100 mmHg over 2-6 hours, then cautiously normalize over 24-48 hours, as recommended by the American College of Cardiology 1
Avoid excessive drops >70 mmHg systolic as this can precipitate cerebral, renal, or coronary ischemia, according to the American Heart Association 1
Patients with chronic hypertension have altered autoregulation and cannot tolerate acute normalization, as stated by the American College of Cardiology 1

Nicardipine: 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 15 minutes, maximum 15 mg/hr, is preferred for most hypertensive emergencies, according to the American College of Cardiology 1
Labetalol: 10-20 mg IV bolus over 1-2 minutes, repeat/double every 10 minutes, maximum cumulative 300 mg, is preferred for encephalopathy, eclampsia, aortic dissection, as recommended by the American Heart Association 1, 2

Do NOT initiate IV medications or rapid BP reduction, as recommended by the American College of Cardiology 2
Up to one-third of patients with elevated BP normalize spontaneously before follow-up, according to the American Heart Association 3, 2
Rapid BP lowering in asymptomatic patients is unnecessary and may precipitate renal, cerebral, or coronary ischemia, as stated by the American College of Cardiology 2

Initiate or adjust oral antihypertensive therapy, including ACE inhibitor or ARB plus calcium channel blocker, as recommended by the American College of Cardiology 1, 2
Target BP <130/80 mmHg over weeks to months, not hours, according to the American Heart Association 1
Arrange urgent outpatient follow-up within 24-48 hours with primary physician for gradual BP reduction, as recommended by the American College of Cardiology 2