Hypertensive crisis

Created 03/11/2022, last revision 06/07/2023


  • a hypertensive crisis is a medical emergency characterized by a sudden and severe elevation in blood pressure
    • the levels of hypertension are not universally established and are arbitrary (usually > 180/120 mmHg)
    • the rate of BP elevation seems more important than its absolute value
    • the term crisis gets abandoned in favor of the following terms
  • the presence of a target-organ lesion distinguishes:
    • hypertensive urgency – without target-organs damage
    • hypertensive emergency – with acute target-organs complications (heart, kidneys, brain, eyes)
  • hypertensive crisis has a mortality rate of up to 7% (Katz, 2009)


  • decompensation of chronic hypertension
    • most commonly caused by sudden discontinuation of antihypertensive medication or drug interactions
    • perioperative
    • acute stroke (which may be a cause or a result of uncontrolled hypertension)
  • secondary hypertension
    • pheochromocytoma
    • preeclampsia/eclampsia
    • abuse of sympathomimetic drugs (amphetamine, LSD, cocaine)

Clinical presentation

  • cerebrovascular
    • hypertensive encephalopathy (confusion, headaches, nausea/vomiting, visual disturbances, seizures)
      • symptoms of hypertensive encephalopathy resolve after blood pressure is lowered and  autoregulation of cerebral flow is restored
    • posterior reversible encephalopathy syndrome (PRES)
    • intracerebral hemorrhage (focal symptoms)
    • subarachnoid hemorrhage (headache, meningeal syndrome)
  • cardiovascular (chest pain, shortness of breath)
    • acute left-sided heart failure (dyspnea, pulmonary edema)
    • acute MI/unstable AP
    • acute aortic dissection (acute and severe chest or back pain)
  • renal
    • acute renal failure
  • eye symptoms
    • hemorrhages, exudates, or edema of the papillae (signs of hypertensive retinopathy grade III or IV) are associated with hypertensive encephalopathy

Diagnostic evaluation

  • repeated BP measurement or continuous BP monitoring
    • start by measuring both arms’ blood pressure (aortic dissection or coarctation, subclavian artery stenosis)
    • if aortic dissection is suspected, also measure BP in the lower limbs
  • look for organ damage
    • blood samples
      • CBC + coagulation
      • renal and hepatic tests
      • NT-proBNP (heart failure)
      • cardiac enzymes (in suspected ACS)
      • urine chemistry and urine sediment examination
      • D-dimers (when aortic dissection is suspected)
    • ECG
    • brain CT + CTA (in patients with acute neurological complaints/signs or case of head injury)
    • chest x-ray (in patients with shortness of breath)
    • CTA of the chest and abdomen for suspected aortic dissection
    • fundoscopic exam (ophthalmoscopy)
  • exclude secondary hypertension
    • CT/MR angiography of renal arteries (renovascular hypertension)
    • plasma renin activity (PRA) and aldosterone, plasma or urine metanephrines
  • arterial blood pressure (BP) monitoring is a mainstay of hemodynamic monitoring in neurocritical care
  • both hypotension and hypertension can impair vital organ function and worsen the outcome
  • BP monitoring techniques:
    • non-invasive BP monitoring (more common)
      • intermittent (inflatable cuff) – the proper cuff size is critical
        • manual (auscultatory, palpatory)
        • automated (oscillometric)
      • continuous
        • volume clamp method
        • arterial applanation tonometry
    • invasive BP measurement via arterial cannulation (most commonly automated)
  • choice of BP monitoring must be individualized
    • low-risk patients – intermittent oscillometric BP monitoring
    • high-risk, hemodynamically unstable patients – continuous BP monitoring (noninvasive or invasive)
    • critically ill patients/hypertensive emergencies – continuous invasive BP monitoring via an arterial catheter is preferred

Proper cuff size

  • the cuff bladder length should be at least 80% of the upper arm circumference
    • arm circumference < 35 cm – cuff 16×30 cm (suitable for most patients)
    • arm circumference 35-44 cm – cuff 16×36 cm
    • arm circumference > 45 cm – cuff 16×42 cm
  • preeclampsia = new onset hypertension >140/90 mmHg + proteinuria > 500 mg/24 h or 300 mg/l occurring after 20 weeks gestation or during the second half of pregnancy
    • most commonly occurs during the 3rd trimester of pregnancy and may occur before, during, or after delivery
  • eclampsia = elevated BP associated with seizures, multi-organ damage (aspiration pneumonia, cerebral hemorrhage, kidney failure, pulmonary edema, HELLP syndrome), and coagulopathy


The severity of a hypertensive crisis depends on:

  • current BP values
  • presence of acute target-organ damage
  • rate of BP increase (how long it took for BP to increase from the baseline values to the current values)
Hypertensive emergency
  • life-threatening condition
  • hypertension + signs of organ damage
    • hypertensive encephalopathy (incl. hyperperfusion syndrome following revascularization procedures – CEA, CAS)
    • cardiac failure +/- pulmonary edema
    • acute coronary syndrome (ACS)
    • aortic dissection
    • SAH/ICH
  • etiology
    • discontinuation of chronic antihypertensive medication
    • pre-/eclampsia
    • pheochromocytoma crisis
  • requires aggressive parenteral therapy
Hypertensive urgency
  • not a life-threatening condition; no signs of organ damage (provoked by acute BP elevation)
  • usually results from the decompensation of chronic hypertension
    • decompensation during invasive procedures, panic attacks, or after administration of psychoactive substances (cocaine, meth)
  •  it can usually be managed on an outpatient basis
  • use oral medications and lower the blood pressure within 24 h

Management of hypertensive emergency

  • admission + monitoring of vital signs (incl. continuous BP monitoring)
  • use analgesia or sedation if needed
  • assess for target organ injury + start parenteral medications (rapid BP lowering is the mainstay of therapy)
  • except for aortic dissection, avoid excessive BP reduction (⇒ risk of cerebral and myocardial hypoperfusion, provocation of arrhythmias, etc.)
    • reduce mean BP by 20-25% in the first hour, then to 160/100 mm Hg over the next 2-6 hours, and then gradually to baseline values over 2 days
    • aortic dissection: reduce SBP to < 100-120 mmHg + reduce heart rate to < 60/min within 20 min
  • use fast-acting and easily titratable antihypertensive drugs –  parenteral drugs allow bolus administration + continuous infusion
    • in patients with significant tachycardia, metoprolol or clonidine (which also has a sedative effect) are appropriate BP-lowering drugs
    • in pregnancy, IV hydralazine or oral nifedipine may be used (avoid ACE inhibitors or ARBs)
    • avoid nitrates in patients with intracranial hypertension
  • start specific treatment of affected organs
Hypertensive emergency
 acute MI / unstable angina nitroglycerin or isosorbide dinitrate (ISOKET)
metoprolol (BETALOC) bolus 1,25–5 mg IV / esmolol (ESMOCARD, BREVIBLOC)
+ urapidil (EBRANTIL)
acute left-sided heart failure loop diuretics + vasodilators
nitroglycerine 1-10 mg/h / ISOKET + FUROSEMIDE (20-40mg)
enalapril (ENAP)
aortic dissection esmolol (ESMOCARD, BREVIBLOC) nebo metoprolol (BETALOC)
nitroprusid (NIPRUSS)
(+ propanol)
reduce SBP  to <
100–120 mm Hg  + HR < 60/min within 20 minutes
hypertensive encephalopathy labetalol (TRANDATE) / urapidil (EBRANTIL) / esmolol (ESMOCARD, BREVIBLOC)
enalapril (ENAP)
→ BP management in an acute stroke
  urapidil (EBRANTIL) / labetalol (TRANDATE)
SAH nimodipine (DILCEREN)  urapidil (EBRANTIL)
abuse of the sympathomimetic drug
  urapidil (EBRANTIL)isosorbide dinitrate (ISOKET) / labetalol (TRANDATE)
preeclampsia/eclampsia labetalol (TRANDATE) / nitropruside (NIPRUSS)
hydralazine i.v.  (2.5–20 mg in eclampsia with the insufficient effect of labetalol)
 renal insufficiency   urapidil (EBRANTIL) / furosemide (20-40mg)
rebound after discontinuing beta-blockers metoprolol (BETALOC)

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Hypertensive crisis