Hypertensive Emergency (ISH 2026)
Hypertensive emergency = very high BP (no fixed threshold, usually ≥180/120 mmHg) WITH acute organ damage (retina, brain, heart, large arteries, kidneys). Needs rapid assessment and immediate, usually IV, BP lowering.
Step 1 — Is there acute organ damage?
No acute organ damage (asymptomatic markedly raised BP) → not an emergency. Usually no admission or IV therapy. Oral antihypertensives + close follow-up.
Acute organ damage present → emergency. Identify the presentation:
| Presentation | Features |
|---|
| Malignant hypertension | Very high BP + acute microvascular damage: bilateral retinal haemorrhages, exudates, papilloedema |
| Hypertensive encephalopathy | Very high BP + lethargy, seizures, cortical blindness or coma, no other cause |
| Hypertensive thrombotic microangiopathy | Very high BP + haemolysis and thrombocytopenia, no other cause, improves with BP lowering |
| Other | Very high BP with stroke, acute coronary syndrome, pulmonary oedema, aortic dissection, severe preeclampsia/eclampsia |
Step 2 — Investigate
ESSENTIAL:
- Cardiovascular and neurological examination
- Haemoglobin, platelets, creatinine, sodium, potassium, LDH, urinalysis (protein, sediment)
- Fundoscopy, ECG
OPTIMAL (by presentation): troponin, chest X-ray, echocardiogram, brain CT/MRI, CT angiography of thorax and abdomen.
A secondary cause is found in 20–40% of malignant hypertension — work it up.
Step 3 — Lower BP by presentation (ESSENTIAL)
Goal: lower BP to safer levels to stop further organ damage while avoiding hypotension. Speed and target depend on the organ involved.
| Presentation | Timeline and target | First-line | Alternative |
|---|
| Malignant hypertension | Several hours; MAP ↓ 20–25% | Labetalol, nicardipine | Nitroprusside, urapidil |
| Hypertensive encephalopathy | Immediate; MAP ↓ 20–25% | Labetalol, nicardipine | Nitroprusside |
| Acute ischaemic stroke, thrombolysis planned, BP >185/110 | 1 h; MAP ↓ ~15% | Labetalol, nicardipine | Nitroprusside |
| Acute ischaemic stroke, BP >220/120 | 1 h; MAP ↓ ~15% | Labetalol, nicardipine | Nitroprusside |
| Acute haemorrhagic stroke, SBP >180 | Immediate; SBP <180 and >130 | Labetalol, nicardipine | Urapidil |
| Acute coronary event | Immediate; SBP <140 | Nitroglycerine, labetalol | Urapidil |
| Acute pulmonary oedema | Immediate; SBP <140 | Nitroprusside or nitroglycerine + loop diuretic | Urapidil + loop diuretic |
| Acute aortic dissection | Immediate; SBP <120 and HR <60 | Esmolol + nitroprusside or nitroglycerine or nicardipine | Labetalol or metoprolol |
| Severe preeclampsia, eclampsia, HELLP | Immediate; SBP <160 and DBP <105 | Labetalol or nicardipine + magnesium sulphate | — |
Key points:
- Rapid lowering is needed in pulmonary oedema and aortic dissection
- BP up to 220/120 may be tolerated temporarily in acute ischaemic stroke when reperfusion is not planned
- Labetalol and nicardipine are safe in most emergencies; nitroglycerine and nitroprusside for cardiac and aortic emergencies. Have them available wherever emergencies are managed
Step 4 — Follow-up (ESSENTIAL)
Patients after a hypertensive emergency have high CV and renal risk.
- Investigate the underlying cause and organ damage (secondary causes common)
- Review monthly until target BP achieved
- Long-term follow-up
Guardrails
- Very high BP alone is not an emergency — organ damage defines it; asymptomatic severe hypertension is managed orally
- Don't drop BP too fast or too far (except aortic dissection and pulmonary oedema) — target a 20–25% MAP fall over hours in malignant hypertension/encephalopathy
- Ischaemic stroke without reperfusion tolerates up to 220/120 — don't over-treat
- Aortic dissection needs both SBP <120 and HR <60 — beta-blockade first
- Magnesium sulphate with antihypertensive in severe preeclampsia/eclampsia
- Look for a secondary cause — present in 20–40% of malignant hypertension
- Drug choice depends on local availability and expertise
Related MD2SKILL skills
ish-htn-pregnancy — preeclampsia/eclampsiaish-htn-resistant-and-secondary — secondary causes workupata-ppgl-hypertensive-crisis-management, ppgl-hypertensive-crisis-management — phaeochromocytoma crisis (different approach — alpha-blockade first)
Source
Stergiou GS, Kario K, Aristizabal D, et al. 2026 International Society of Hypertension Global Hypertension Practice Guidelines. J Hypertens. 2026;44. DOI: 10.1097/HJH.0000000000004451. Section 9.6; Table 15 (adapted by ISH from its reference 174).