Management of Accelerated Hypertension

Definition and Classification

Accelerated hypertension is characterized by severely elevated blood pressure with acute hypertension-mediated organ damage, typically manifesting as retinopathy, acute renal failure, and/or thrombotic microangiopathy, according to the European Society of Cardiology 3
Hypertensive emergencies require immediate blood pressure reduction to limit extension or promote regression of acute organ damage, as recommended by the European Society of Cardiology 3
Patients without acute end-organ damage have hypertensive urgency, not emergency, and can usually be treated with oral agents, as stated by the European Society of Cardiology 3

The type of target organ damage determines the choice of treatment, target BP, and timeframe for BP reduction, according to the European Society of Cardiology 3
For malignant hypertension with or without thrombotic microangiopathy or acute renal failure, aim to reduce mean arterial pressure by 20-25% over several hours, as recommended by the European Society of Cardiology 1
Patients with hypertensive emergencies should be admitted for close monitoring and, in most cases, treated with intravenous BP-lowering agents, as stated by the European Society of Cardiology 3

Intravenous labetalol is recommended as first-line treatment for most hypertensive emergencies, including malignant hypertension and hypertensive encephalopathy, by the European Society of Cardiology 1, 2
For severe hypertension, drug treatment with IV labetalol, oral methyldopa, or nifedipine is recommended, according to the European Society of Cardiology 4
Sodium nitroprusside, nicardipine, and urapidil are effective alternatives for malignant hypertension, as stated by the European Society of Cardiology 1

In acute ischemic stroke with BP >220/120 mmHg, careful BP lowering with IV therapy to reduce mean arterial pressure by 15% is recommended, by the European Society of Cardiology 2
For acute hemorrhagic stroke with systolic BP >180 mmHg, immediate BP reduction to 130-180 mmHg is recommended, as stated by the European Society of Cardiology 2
In patients with acute intracerebral hemorrhage, immediate BP lowering is not recommended for systolic BP <220 mmHg, according to the European Society of Cardiology 4

Avoid excessive or rapid blood pressure reduction, which can lead to organ hypoperfusion, as warned by the European Society of Cardiology 5
Do not attempt to normalize blood pressure during the initial emergency department visit, as recommended by the American College of Emergency Physicians 7