1. What It Is

A hypertensive crisis is when blood pressure shoots up to dangerous levels—usually ≥180 systolic or ≥120 diastolic.
There are two types:

• Hypertensive Emergency: High BP with acute end-organ damage
• Hypertensive Urgency: High BP without end-organ damage

2. Causes

Hypertensive crises usually happen when something suddenly pushes the BP up or when a chronic hypertensive loses control.

Common Causes

• Medication issues:
  • Missing doses
  • Sudden withdrawal (especially clonidine, beta-blockers)
• Kidney problems:
  • AKI, CKD progression, glomerulonephritis
  • Renal artery stenosis
• Stimulant use:
  • Cocaine, amphetamines, MDMA
• Endocrine causes:
  • Pheochromocytoma
  • Thyroid storm
  • Hyperaldosteronism
  • Cushing’s
• Pregnancy:
  • Pre-eclampsia/eclampsia
• Neurologic:
  • Stroke, intracranial hemorrhage, head injury
• Others:
  • Severe pain, stress, alcohol withdrawal.

3. Signs & Symptoms

Symptoms depend on which organ is being affected.
In hypertensive emergency, something is actively being damaged.

General

• Severe headache
• Blurred vision
• Nausea/vomiting
• Chest pain
• Shortness of breath
• Confusion or altered mental status

Organ-Specific Clues

• Brain: confusion, seizures, focal deficits, encephalopathy
• Heart: chest pain, pulmonary edema, acute heart failure
• Kidneys: reduced urine output, rising creatinine
• Eyes: papilledema, retinal hemorrhages
• Aorta: tearing chest/back pain (aortic dissection)

If none of these are present → more likely hypertensive urgency.

4. Investigations

You’re mainly looking for evidence of end-organ damage.

Basic Tests

• BP measurement in both arms
• ECG → ischemia, LVH, arrhythmias
• CXR → pulmonary edema or widened mediastinum
• Urinalysis → protein, blood
• Renal function tests → creatinine, urea
• Electrolytes

Targeted Tests

• CT brain if any neurologic symptoms
• Troponins for chest pain
• Echo if heart failure suspected
• CT angiography if you suspect aortic dissection
• Pregnancy test in women of child-bearing age

5. How to Diagnose

Hypertensive Emergency

1. BP ≥180/120
2. Clear evidence of acute organ damage

If BOTH → emergency.

Hypertensive Urgency

• Very high BP
• NO acute organ dysfunction on history, exam, or tests

6. Treatment

Hypertensive Emergency

• Admit to ICU
• Start IV antihypertensives
  • Nicardipine
  • Labetalol
  • Nitroprusside
  • Esmolol
  • Nitroglycerin (if ACS or pulmonary edema)

BP Goal

• Lower MAP by no more than 25% in the first hour
• Then to ~160/100 in the next 2–6 hours
• Never drop BP too fast — you’ll worsen ischemia.

Specific exceptions:

• Aortic dissection: rapid BP + HR control aggressively
• Ischemic stroke: BP goals depend on thrombolysis plans
• Eclampsia: magnesium sulfate + labetalol/hydralazine

Hypertensive Urgency

• No ICU needed
• Give oral medications (e.g., captopril, clonidine, labetalol)
• Dermal or Oral Nitrates
• Gradually lower BP over 24–48 hours
• Adjust outpatient regimen
• Close follow-up

Also check out our other summaries :

Med Bites : How to diagnose Pulmonary Embolism

Med Bites : Bronchial Asthma

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