Hypertensive emergency and urgency !

A hypertensive crisis is a very high blood pressure. It is an emergency when it is acutely damaging the brain, heart, kidneys or vessels.

Updated 2026-11-01

Structures involved

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In the clinical exam

Why it happens

What it is

Severely raised blood pressure, commonly above about 180/120 mmHg. It is a hypertensive emergency when there is new or worsening target-organ damage, and a hypertensive urgency (severe asymptomatic hypertension) when there is none.

Who gets it

Arterial hypertension is very common in Colombia and Latin America and is often undiagnosed or poorly controlled, so hypertensive crises are frequent in emergency departments. Most are urgencies; true emergencies are fewer but carry high mortality.

Causes

Poorly controlled chronic hypertension or stopping antihypertensive drugs (the most common cause)
Kidney disease: acute glomerulonephritis, renal artery stenosis
Pre-eclampsia and eclampsia
Catecholamine excess: pheochromocytoma, cocaine or amphetamine use, abrupt clonidine withdrawal
Acute pain, anxiety or urinary retention (raise blood pressure without true emergency)

Risk factors

Untreated or poorly adherent hypertension
Chronic kidney disease
Pregnancy
Stimulant drug use
Limited access to follow-up and medicines

Pathophysiology

A sudden rise in vascular resistance overwhelms autoregulation in arterioles. Endothelial injury, fibrinoid necrosis and microthrombi cause ischaemia in the brain, retina, kidney and heart, and pressure-driven natriuresis causes volume depletion that activates the renin-angiotensin system, driving a further rise in pressure. Chronic hypertension shifts autoregulation upward, so a too-fast fall in pressure can also cause ischaemia.

Classification

Hypertensive emergency: severe hypertension with acute target-organ damage
Hypertensive urgency: severe hypertension without acute target-organ damage
Malignant hypertension: severe hypertension with retinal haemorrhages, exudates or papilloedema

Symptoms and signs

Severe headache, blurred vision, confusion or seizures (hypertensive encephalopathy)
Chest pain or tearing pain radiating to the back
Dyspnoea and orthopnoea from acute pulmonary oedema
Focal neurological deficit
Reduced urine output or blood in the urine
Often no symptoms in a hypertensive urgency

Diagnosis

Clinical: Repeated blood pressure in both arms with a proper cuff, and a focused search for target-organ damage: neurological examination, fundoscopy (haemorrhages, exudates, papilloedema), heart and lung examination, pulses and urine output.
Tests: ECG and troponin; creatinine, electrolytes and urinalysis (protein, red cells); complete blood count and smear for haemolysis; pregnancy test in women of childbearing age; urine toxicology when stimulants are suspected.
Imaging: Chest X-ray for pulmonary oedema or a widened mediastinum; brain CT or MRI with neurological signs; CT angiography or echocardiography when aortic dissection is suspected.

Differential diagnosis

Pain- or anxiety-driven rise in blood pressure
Primary stroke or intracerebral haemorrhage with reactive hypertension
Aortic dissection
Pre-eclampsia
Stimulant intoxication or alcohol withdrawal

Goal of treatment

In an emergency, lower blood pressure in a controlled, gradual way (usually by no more than about a quarter in the first hour) to stop organ damage without causing ischaemia; in an urgency, lower it over hours to days with oral treatment and secure follow-up.

Treatment

Acute: Hypertensive emergency: admission to intensive care with an arterial line and short-acting, titratable intravenous agents (for example labetalol, nicardipine, clevidipine, esmolol or nitroprusside), chosen by the organ involved.
Acute: Special situations: aortic dissection needs rapid lowering of heart rate and pressure with a beta-blocker first; acute ischaemic stroke usually allows higher pressures; pulmonary oedema benefits from nitrates and loop diuretics; pre-eclampsia uses magnesium sulfate plus labetalol or hydralazine.
Acute: Catecholamine excess (pheochromocytoma, cocaine): alpha-blockade (phentolamine) and benzodiazepines; a beta-blocker alone is avoided.
Medical: Hypertensive urgency: restart or adjust oral antihypertensives and lower pressure gradually, avoiding rapid-acting agents that cause sudden drops.
Follow-up: Frequent blood pressure and neurological checks, urine output, kidney function and cardiac monitoring; then education on adherence and close outpatient follow-up.

Complications

Ischaemic stroke, intracerebral haemorrhage and hypertensive encephalopathy
Acute coronary syndrome and acute heart failure with pulmonary oedema
Aortic dissection
Acute kidney injury
Eclampsia and HELLP syndrome in pregnancy
Organ ischaemia from lowering blood pressure too quickly

Prognosis

Untreated hypertensive emergency has high short-term mortality; with timely treatment most survive, but long-term cardiovascular and kidney risk stays high. Urgencies have a good short-term outlook when follow-up is secured.

Prevention

Diagnosis and sustained control of chronic hypertension
Adherence to antihypertensive treatment and regular follow-up
Avoiding stimulant drugs

Test yourself

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What distinguishes a hypertensive emergency from a hypertensive urgency?

Acute target-organ damage (brain, heart, aorta, kidney, retina) is present in an emergency and absent in an urgency.

How fast is blood pressure usually lowered in a hypertensive emergency?

Gradually: by no more than about 25% in the first hour, with exceptions such as aortic dissection, which needs faster lowering.

Why is a beta-blocker alone avoided in cocaine- or pheochromocytoma-induced crisis?

Unopposed alpha-adrenergic vasoconstriction can raise blood pressure further; alpha-blockade and benzodiazepines are used instead.

Which fundoscopic findings define malignant hypertension?

Retinal haemorrhages, cotton-wool spots or exudates, and papilloedema.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Malignant hypertension: MedlinePlus Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2026).

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Left ventricle highlighted on the Durgical 3D model