Treatment of Hypertensive Emergencies


Reduce blood pressure, though not all at once:

  • Reduce systolic blood pressure by no more than 25% in the first hour 

  • If stable, reduce to 160/100 mmHg over the next 2-6 hours 

  • Goal to reduce to normal blood pressure over following 24-48 hours 


*Need to balance the reduction of blood pressure with avoidance of end organ hypoperfusion. More aggressive blood pressure control is needed for acute aortic dissection, pheochromocytoma crisis, severe preeclampsia/eclampsia, and intracerebral hemorrhage


Choosing the Correct Antihypertensive Agent 

The choice of medical therapy needs to be tailored to the underlying pathophysiology and specific end organ damage identified. The following is a quick guide, useful in most situations, though there may be variability in best agent depending on the individual patient and disease 


Acute Pulmonary Edema 

  • Caused by decrease in venous capacitance. Leads to fluid shifts into pulmonary circulation. Goal with treatment is vasodilation 

  • Treat with SL, IV, or topical Nitrates 

  • Can augment with IV infusions of nitroprusside or nicardipine 


Acute Myocardial Infarction 

  • Goal is to reduce ischemia and avoid >25% reduction of MAP 

  • Treat with SL, IV or topical nitrates and IV esmolol 

  • Can also consider IV labetalol or metoprolol 


Sympathetic Crisis 

  • Cocaine, amphetamine, MAOI toxicity 

  • Benzodiazepine IV bolus 

  • Can augment with IV phentolamine, nicardipine, or nitrates  


Acute Renal Failure 

  • Reduce BP by no more than 20% 

  • IV fenoldopam or nicardipine 


Eclampsia, Preeclampsia 

  • Goal SBP <140mm Hg over first hour *different than standard guidelines* 

  • IV hydralazine or labetalol. Oral nifedipine if no IV access 


Hypertensive Encephalopathy 

  • Decrease MAP 20-25%. More aggressive lowering may lead to ischemia 

  • IV labetalol or nicardipine 


Subarachnoid Hemorrhage 

  • Goal SBP <160 mmHg to prevent rebleeding 

  • IV nicardipine, labetalol, esmolol 


Intracerebral Hemorrhage 

  • Treat aggressively if SBP >220 mmHg. Boluses of antihypertensives can be used if SBP 150-220 mmHg 

  • IV labetalol, esmolol, nicardipine 


Aortic Dissection 

  • Reduce shear forces and lower SBP to 100-120 mmHg and HR <60 BPM 

  • Esmolol IV bolus and then infusion 

  • Can augment with labetalol, nicardipine, or nitroprusside 


Acute Ischemic Stroke 

  • If TPA candidate, treat if BP remains > 185/110 mmHg 

  • If not TPA candidate, treat if BP remains > 220/120 mmHg 

  • Labetalol 10-20mg IV over 1-2 minutes. May repeat once 

  • Nicardipine infusion. Start at 5mg/hr and titrate up by 2.5mg/hr every 5-15 mintues 

  • Avoid excessive blood pressure drops to avoid worsening ischemia 




Most patient requiring IV infusions of blood pressure lowering agents will require ICU level of care with the ultimate goal of titrating off IV drips and transition to oral medications 




1. Baumann, Brigitte M. Systemic Hypertension. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.),Eds. Judith E. Tintinalli, et al.eds.Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020. 

2. Peixoto AJ. Acute Severe Hypertension. N Engl J Med. 2019 Nov 7;381(19):1843-1852. doi: 10.1056/NEJMcp1901117. PMID: 31693807.