Hypertensive Crisis Management

Definition and Diagnosis

The American College of Cardiology defines hypertensive emergency as blood pressure >180/120 mmHg WITH acute target organ damage, which requires immediate ICU admission and IV therapy 1, 2, 3
The presence of acute target organ damage, such as neurologic, cardiac, vascular, renal, ophthalmologic, or obstetric damage, distinguishes hypertensive emergency from hypertensive urgency 1, 2, 3
Hypertensive urgency is defined as blood pressure >180/120 mmHg WITHOUT acute target organ damage, and patients are otherwise stable with no acute or impending change in target organ function 1, 2, 3

For hypertensive emergency, the American College of Cardiology recommends immediate ICU admission with continuous monitoring and IV therapy, using first-line IV agents such as nicardipine, clevidipine, labetalol, or sodium nitroprusside 1, 2, 3
The goal of BP reduction in hypertensive emergency is to reduce SBP to <140 mmHg within the first hour for compelling conditions, and to reduce SBP by no more than 25% within the first hour for non-compelling conditions 1, 2, 3
For hypertensive urgency, the American College of Cardiology recommends outpatient management with oral antihypertensives, gradual BP reduction over 24-48 hours, and follow-up within 2-4 weeks 1, 3

The American College of Cardiology recommends confirming BP >180/120 mmHg with repeat measurement, assessing for symptoms suggesting organ damage, and performing a focused exam to determine the presence of target organ damage 2
If target organ damage is present, patients should be admitted to the ICU for IV therapy, and if no target organ damage is present, patients can be managed as outpatients with oral antihypertensives 1, 2, 3
The American College of Cardiology also recommends avoiding excessive drops in BP, as this can precipitate cerebral, renal, or coronary ischemia, especially in patients with chronic hypertension 1, 2