Clinical exam · Cardiovascular system
Hypertensive emergency: target-organ signs !
- Syndrome
Very high blood pressure is an emergency when it is already harming the brain, eyes, heart, aorta or kidney; the exam looks for that harm.
Updated 2026-11-01
See it in 3D: Retina · Kidneys · Left ventricle · Thoracic aorta
What it is
A hypertensive emergency is a severe rise in blood pressure, usually 180/120 mmHg or more, with acute target-organ damage. Without acute damage it is severe uncontrolled hypertension (formerly 'urgency'). What defines the emergency is the damage, not the number alone.
Key findings
- Brain: severe headache, vomiting, confusion, seizures, visual disturbance (hypertensive encephalopathy); focal deficit (stroke).
- Eyes: blurred vision; fundus with hemorrhages, cotton-wool spots or papilledema.
- Heart: chest pain (acute coronary syndrome), dyspnea with crackles (acute pulmonary edema).
- Aorta: tearing back pain, pressure difference between arms. Kidney: oliguria, hematuria, proteinuria, rising creatinine.
- Pregnancy: pressure of 160/110 mmHg or more with headache, visual change, epigastric pain or seizures: severe preeclampsia or eclampsia.
Pathophysiology
- Very high pressure overwhelms autoregulation of cerebral and renal flow: cerebral edema, fibrinoid necrosis of arterioles, hemorrhages.
- The left ventricle faces a very high afterload: ischemia and acute pulmonary edema.
- The aortic wall is under more stress: risk of dissection.
- Arteriolar changes show in the retina: flame hemorrhages, cotton-wool spots and papilledema.
Common causes
- Stopping antihypertensive treatment, the most common cause.
- Renovascular hypertension, acute glomerulonephritis, chronic kidney disease.
- Cocaine, amphetamines, abrupt withdrawal of clonidine or beta-blockers; pheochromocytoma.
- Preeclampsia and eclampsia.
Tests that confirm it
- Confirm the reading with the right cuff, in both arms, with the patient at rest.
- Creatinine, urinalysis, electrolytes, blood count with smear (microangiopathic hemolysis), troponin, ECG.
- Fundoscopy; head CT if there are neurological signs; CT angiography if dissection is suspected.
Test yourself
Think of the answer, then tap the question to see it.
What separates a hypertensive emergency from severe hypertension without an emergency?
Acute target-organ damage (brain, eye, heart, aorta, kidney); the number alone does not define it.
Which fundus findings indicate severe hypertensive retinopathy?
Flame hemorrhages, cotton-wool spots and papilledema.
Which symptoms suggest hypertensive encephalopathy?
Severe headache, vomiting, confusion, visual disturbance and seizures.
See it in 3D
The structures of Durgical's 3D anatomy where it is found.
Related
- Blood pressure measurement
- Fundoscopy: the optic disc, papilledema and retinopathy
- Chest pain: ischemic, pericardial, pleural and other patterns
- Heart failure syndrome: left- and right-sided signs
Related conditions
- Hypertensive emergency and urgency
- Arterial hypertension
- Aortic dissection
- Ischaemic stroke
- Renovascular hypertension (renal artery stenosis)
- Hypertensive heart disease
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Malignant hypertension: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); Chest pain: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024).
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Representative model, for educational purposes only.