Hypertensive Crisis

systolic blood pressure (SBP) level ≥180 mmHg and/or a diastolic blood pressure (DBP) level ≥ 120 mmHg with or without acute target organ damage (TOD).

Hypertensive Urgency

  • It is defined as elevation BP greater than 180/120 mm Hg, without signs of Target Organ Damage (TOD).
  • Presenting symptoms include headache, shortness of breath, anxiety, and epistaxis.

Hypertensive Emergency

  • It is defined as elevation of BP greater than 180/120 mm Hg in presence of signs of TOD
  • Global burden – 24% & 21% of male & females with HTN (SBP>=140 OR DBP>=90).

India – Prevalence of HTN is 25% in urban & 10% in rural people in India of which 20.6% are men & 20.9% women.


  • Non-adherence to anti-hypertensive medication
  • Renovascular Disease
  • Pheochromocytoma
  • Hyperaldosteronism
  • Drug Induced hypertension
  • Eclampsia/pre-eclampsia
  • Vasculitis


  • History – Hypertension, Medications, Substance abuse, Comorbid conditions
  • BP – Both arms, Supine & Standing (Aortic dissection)
  • Cardiac – ECG, Cardiac Enzymes, 2D-echo, X-ray
  • Renal – Serum Creatinine & BUN, Liver Enzymes


  • Not addressed in recent JNC-8
  • Current recommendations based on
    • JNC-7 guidelines
    • ACC/AHA 2017

Normalisation of BP is usually not recommended

  • Sudden fall in BP may cause acute hypoperfusion of vital organs & results in myocardial ischemia, hemiplegia, or  acute renal failure.

Hypertensive Urgency

  • Remember: Start Low, Go Slow
  • Fully titrate before adding second med
  • Titrate to effect (or side effect)
  • Treatment with an oral, short-acting agent such as Captopril, Labetalol
  • Increasing dose, Use of combination

Goal of Therapy: Hypertensive Emergency

  • <1hr à Reduce Systolic Blood Pressure(SBP) ≤ 25%
    • 2-6hr à if stable, reduce to 160/100–110 mmHg
    • 24-48hr à Well tolerated & stable toward normal BP


  1. Vasodilators
    1. Sodium nitroprusside
    1. Nitro-glycerine
    1. Nifedipine
    1. Nicardipine
    1. Clevidipine
    1. Fenoldopam
    1. Hydralazine
    1. Enalaprilat
  2. Adrenergic inhibitors
    1. Labetalol
    1. Esmolol
    1. Phentolamine

Sodium Nitroprusside – MOA – Preload & afterload

  • Arteriolar & venous dilation, cerebral vasodilation
  • DOSE- 0.3–0.5 mcg/kg/min IV infusion, max – 10 mcg/kg/min

Ultra short acting -1-2min, t ½ 3-4 minutes

  • Adverse Effect/Precaution-
  • Cyanide & thiocyanate toxicity prolonged infusion,      
  • Thiosulfate – to prevent cyanide toxicity
  • Bottle is covered with an opaque wrapping
  • Continuous BP monitoring
  • Use à Aortic dissection,  Acute LVF


  • MOA- Greater preload reduction than afterload, Decreases coronary vasospasm
  • DOSE- 5-100mcg/min, Titrate up 10mcg every 5 mins

Onset 2-5min, Half life – 4min

  • Adverse Effect/Precaution- Headache, Tachycardia, Tolerance, Continuous BP monitoring

C/I- Head trauma/Cerebral haemorrhage, with PDE-5 inhibitors

  • Uses – Acute HF,  Acute coronary syndrome.

Oral/Sublingual Nifedipine

  • MOA- Peripheral & coronary arteriolar dilator, Potential hypotension and/or reflex cardiac stimulation

Sudden uncontrolled & severe reductions in BP,  may precipitate  cerebral, renal & myocardial ischemic events

  • “Inappropriate physician habits in prescribing nifedipine capsules in hospitalized patients”
  • Cardiorenal Advisory Committee of FDA has concluded  “that practice of administering SL/oral nifedipine abandoned because this is not safe nor efficacious1


  • MOA- L-type Ca++ channel blocker – selective Arterial vasodilator, Cerebral & Coronary vasodilatation
  • DOSE- Start 5mg/hr IV infusion, titrate every 15min to max 15mg/hr

Duration of action 15-30min,

Adverse Effect/Précaution- Worsen/cause HF,  Reflex tachycardia

  • Uses – Ideal for CNS emergencies, Renal Disease


  • MOA- 3rd gen (L-type) CCB, arterial vasodilator FDA approval (2008), Injectable emulsion
  • DOSE- Start 1-2mg/hr with rapid titration to max 32mg/hr

Ultra short t1/2 – 1 min, Duration of action 5-15min, PPB -99.9%

  • Adverse Effect/Precaution- Atrial fibrillation, C/I – Allergies (soy & egg products), Defective lipid metabolism
  • Uses – All HTN emergencies (Safe in Renal & Hepatic dysfunction)


  • MOA- Peripheral  Dopamine-1  agonist(DA1). 10 –fold more potent renal vasodilator than Dopamine
  • DOSE- 01-0.3mcg/kg/min infusion, Max infusion rate – 1.6mcg/kg/min (Titratable, Predictable & Stable)
  • Adverse Effect/Precaution- Tachycardia, Headache, Hypokalemia. Caution with glaucoma.
  • Advantages- All HE, Renal insufficiency patients  Strokes (combination with Nicardipine)


  • MOA- Direct arteriolar dilator, opening high conductance Ca2+-activated K+ channels

Delayed onset, Unpredictable hypotensive effect

  • DOSE- Dose: 10-20 mg I V, repeated in 30 mins, 10-40mg IM. Not titratable
  • Adverse Effect/Precaution- TACHYCARDIA,  Drug-induced Lupus syndrome

Aggravation of angina, Sodium & water retention

  • Advantages- Eclampsia


  • MOA- Active component of Enalapril,  ACE inhibitor
  • DOSE- 1.25-5mg IV every 6hr. Difficult to titrate
  • Adverse Effect/Precaution- Excessive fall in BP, C/I- Acute MI, Renal Disease,  Pregnancy, Volume depletion
  • Use – Acute LVF , Expensive


  • MOA- Cardio selective β Blocker
  • DOSE- Loading dose 500mcg/kg over 1 min, Infusion of 50-300mcg/kg/min
  • Adverse Effect/Precautions- Bradycardia

C/I- 1st degree heart block, COPD, CKD

  • Uses- Aortic Dissection, Cardioprotective in CVS emergencies


  • MOA- Selective α1 and non-selective β blocker (1:7)

Maintains cardiac output, Cerebral, renal, coronary blood flow, Reduces SVR

  • DOSE- 20-80mg IV Bolus every 10min, or infusion of 2mg/min to max of 300mg.
  • Adverse Effect/Precautions- Exacerbate CHF, C/I – COPD, Heart Block, decompensated HF
  • uses- PIH, Pheochromocytoma


  • MOA- α adrenergic blocker
  • DOSE- Bolus 5-20mg IV every 5min,
  • Adverse Effect/Precaution- Tachycardia, flushing, Postural Hypotension

C/I- use with PDE-5 inhibitors, Renal Impairment

  • Advantages- Pheochromocytoma, Cocaine associated HPT crisis

Management of Hypertensive Emergency with TOD

Pulmonary Edema (LVF)

  • Nitroglycerin 5 mcg/min.
  • Sodium Nitroprusside (reduces preload) -0.3 to 0.5 mcg/kg/min
  • IV Diuretic (reduces preload & afterload)- 40mg IV
  • Morphine – Vasodilator & Sympatholytic
  • Clevidipine infusion 1–2 mg/h, max 32 mg/h.
  • Low EF à Avoid beta blockers/Negative inotropes

Acute Myocardial Infarction

  • Reduce MAP by 20 -25% of baseline
  • Nitrates should be given till symptoms subside or until DBP<100
  • Drug of choice: Nitroglycerine 5 mcg/min, Labetalol (or Esmolol), Nicardipine – 5 mg/h
  • Avoid Hydralazine – Increase myocardial O2 demand

Acute Aortic Dissection

  • OK to aggressively reduce BP (<120/80)
  • Reducing the shear stress on aortic wall
  • Aim of treatment to reduce SBP as rapidly as possible down to 100-110 mmHg & to control tachycardia
  • 1st Esmolol then Nitroprusside
  • Hydralazine is C/I

Ischemic Stroke

  • Blood Pressure -Systolic > 185 or diastolic > 110 mm Hg
  • Labetalol 10 to 20 mg IV over 1 to 2 min may repeat x 1                     or
  • Nicardipine infusion, 5 mg/h, titrate up by 0.25 mg/h to max dose 15 mg/h
  • Desired blood pressure obtained, reduce to 3 mg/h
  • If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside

Sympathetic crises

  • PATHOLOGY- Pheochromocytoma, Monoamine oxidase inhibitor + tyramine, Cocaine/amphetamines overdose.
  • GOAL- Reduce MAP by ~25% over several hours
  • DOC- Phentolamine: 5-15mg IV bolus or drip 5-10mcg/kg/min

Beta-blocker- Labetalol (control tachycardia)

Benzodiazepines – Helpful in cocaine/amphetamine overdose

Pre-eclampsia and Eclampsia

  • PATHOLOGY- Systemic arterial vasoconstriction (Including Placental)
  • Defined as SBP = 140/90 mmHg or greater, OR a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline
  • Restlessness & hyper-reflexia , seizures, proteinuria
  • GOAL- Delivery of the fetus and placenta
  • DOC- MgSO4: 4-6gm over 15 minutes IV, drip 1-2gm/hr
  • Hydralazine: 5-10mg IV, drip 5-10mg/hr
  • Labetalol: 20mg IV, repeat prn q 10 mins, drip 1-2mg/min

Intracerebral Hemorrhage

Rise in BP due to increased ICP & irritation of ANS

  • GOAL- Treatment based on clinical/radiographic evidence

Raised ICP – MAP<130 (1st 24hrs)

No raised ICP – MAP<110

To prevent re-bleeding & reduce edema.

BP >180/105 mmHg , benefit from gradual 20-25% reduction in BP

  • DOC- IV Nicardipine 2mg bolus, then 4-15mg/hr (treat SAH )

Nimodipine PO 60mg q 4hr (to reverse vasospasm)

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