# 🚨 Hypertensive Emergencies vs Severe HTN

## 🩺 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 ↓ Acute End-Organ Damage Present? No ↓ **Severe HTN Without Target Organ Damage**\
Asymptomatic severe HTN (≥180/120) ↓ **Class 3 Recommendation:**\
NO acute IV treatment\
Oral adjustment + close follow-up\
1-2 weeks Yes ↓ **Hypertensive Emergency**\
Acute target organ damage ↓ Staged BP reduction\
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

Initial SBP (mmHg): 220 Initial DBP (mmHg): 130 Clinical Scenario: Time Frame: Patient Age: 65 years 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

## 📚 Sources

1.  **Rastogi R, Sheehan MM, Hu B, et al.** Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. *JAMA Intern Med.* 2021;181(3):345-352. [PMID: 33369614](https://pubmed.ncbi.nlm.nih.gov/33369614/). \[Source for: hospital antihypertensive intensification associated with AKI 10.3% vs 7.9% and myocardial INJURY (not infarction) 1.2% vs 0.6%; n=22,834.\]
2.  **Anderson CS, Heeley E, Huang Y, et al; INTERACT2.** Rapid blood-pressure lowering in acute intracerebral hemorrhage. *N Engl J Med.* 2013;368(25):2355-2365. [PMID: 23713578](https://pubmed.ncbi.nlm.nih.gov/23713578/).
3.  **Qureshi AI, Palesch YY, Barsan WG, et al; ATACH-2.** Intensive BP Lowering in Acute Cerebral Hemorrhage. *N Engl J Med.* 2016;375(11):1033-1043. [PMID: 27276234](https://pubmed.ncbi.nlm.nih.gov/27276234/).
4.  **Whelton PK, Carey RM, Aronow WS, et al.** 2017 ACC/AHA Guideline for High Blood Pressure in Adults. *Hypertension.* 2018;71(6):e13-e115. [PMID: 29133356](https://pubmed.ncbi.nlm.nih.gov/29133356/). \[Source for: hypertensive emergency vs urgency definitions; target organ damage criteria; treatment goals.\]

📚 For Educational Purposes Only

© 2025 Andrew Bland MD - All Rights Reserved


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[Website version](https://urinenephrology.org/2025_UDPA_Lectures_Live/hypertension/inpatient-emergencies.html) · Markdown synchronized October 3, 2026.