🩺 2025 Updated: Hypertensive Emergency vs Severe HTN Algorithm
🆕 2025 Guideline Changes
"Hypertensive Urgency" terminology has been retired. Now classified as "Severe Hypertension Without Target Organ Damage" - Class 3 recommendation against acute IV treatment for asymptomatic patients.
Markedly Elevated Blood Pressure
SBP ≥ 180 and/or DBP ≥ 120
SBP ≥ 180 and/or DBP ≥ 120
↓
Acute End-Organ Damage Present?
No
↓
Severe HTN Without Target Organ Damage
Asymptomatic severe HTN (≥180/120)
Asymptomatic severe HTN (≥180/120)
↓
Class 3 Recommendation:
NO acute IV treatment
Oral adjustment + close follow-up
1-2 weeks
NO acute IV treatment
Oral adjustment + close follow-up
1-2 weeks
Yes
↓
Hypertensive Emergency
Acute target organ damage
Acute target organ damage
↓
Staged BP reduction
25% in first hour, then
<160/100 over 2-6 hours
ICU monitoring
25% in first hour, then
<160/100 over 2-6 hours
ICU monitoring
🎯 End-Organ Damage Recognition
🧠 Neurological
- Hypertensive Encephalopathy: Altered mental status, headache
- Stroke: Ischemic or hemorrhagic
- Seizures: New onset or recurrent
- Papilledema: Optic disc swelling
- Retinal Changes: Hemorrhages, exudates
❤️ Cardiovascular
- Acute MI: Chest pain, ECG changes
- Aortic Dissection: Tearing chest/back pain
- Acute Heart Failure: Pulmonary edema
- Unstable Angina: New or worsening chest pain
- Arrhythmias: Life-threatening rhythms
🫘 Renal
- Acute Kidney Injury: Rising creatinine
- Hematuria: Glomerular bleeding
- Proteinuria: New or worsening
- Oliguria: Decreased urine output
- Electrolyte Abnormalities: Acute changes
🫁 Pulmonary
- Acute Pulmonary Edema: Dyspnea, orthopnea
- Respiratory Distress: Hypoxemia
- Chest X-ray Changes: Infiltrates, effusions
- Reduced O2 Saturation: <90% on room air
💊 Antihypertensive Selection Guide
🎯 First-Line Agent Selection
🫀 Ischemic Heart Disease
First Choice: Metoprolol, Clevidipine
Avoid excessive reduction
💔 Heart Failure
First Choice: Clevidipine, Esmolol
Careful with beta-blockers
🧠 Stroke
First Choice: Labetalol, Clevidipine
Target <180/105 if candidate for lysis
🫘 Kidney Disease
First Choice: Clevidipine, Nicardipine
Preserve renal perfusion
🧮 Blood Pressure Reduction Calculator
Target BP Calculator
Calculating target blood pressure...
📋 Drug Dosing Quick Reference
💉 IV Agents (Emergency)
- Clevidipine: 1-2 mg/hr, titrate q90s
- Nicardipine: 5 mg/hr, titrate q15min
- Labetalol: 20mg IV, then 40-80mg q10min
- Esmolol: 500 mcg/kg load, then 50-300 mcg/kg/min
- Hydralazine: 10-20mg IV q4-6h (avoid in CAD)
💊 PO Agents (Urgency)
- Metoprolol: 25-50mg BID
- Amlodipine: 5-10mg daily
- Lisinopril: 10-20mg daily
- Clonidine: 0.1-0.2mg q1h PRN (max 0.6mg)
- Captopril: 25mg SL q15-30min PRN
⚠️ Critical Safety Points
🚫 Avoid Excessive Reduction
- Target 10-20% reduction in first hour
- Avoid >25% reduction acutely
- Risk of stroke, MI, AKI
⚡ Contraindicated Agents
- Sublingual nifedipine (unpredictable)
- Immediate-release nifedipine
- Hydralazine in CAD/stroke
🎯 Monitoring Essentials
- Continuous cardiac monitoring
- Neuro checks every 15 minutes
- Urine output monitoring