• Differentiate between hypertensive emergency and urgency.
• Assess for target organ damage (heart, brain, kidneys).
• Initiate immediate antihypertensive medications in hypertensive emergencies.
• Do not treat hypertensive urgency with immediate medications; refer to primary care.
• Investigate for secondary causes if the patient is young or has resistant hypertension.

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Abbreviations

1. Categorizing Blood Pressure

• Hypertensive emergency: Severely elevated BP (usually >180/120 mmHg) associated with new or progressive target organ dysfunction.

• Hypertensive urgency: BP is above 180/120 mmHg but the patient is stable and there is no organ dysfunction.

• Uncontrolled essential hypertension: Asymptomatic elevated BP less than 180/120 mmHg.

2. Assessing for Target Organ Damage

a) History

• Cardiac symptoms: chest pain, shortness of breath, syncope

• Neurological symptoms: headache, visual changes, focal weakness or numbness, altered mental status, seizures

• Renal symptoms: Decrease urine output

b) Examination

• Cardiac signs: differential blood pressure, radio-radial/femoral delay, pulmonary edema

• Neurological signs: any acute neurological deficit, including retinopathy

• Renal signs: oliguria, anuria, proteinuria

c) Investigation

• Baseline

  • FBC

  • Blood chemistry (renal function, electrolytes)

  • Urinalysis

  • ECG

• Others

  • If features of coronary ischemia: Troponin

  • If features of heart failure: Chest X-ray and/or BNP

  • If neurological issues: Brain imaging and/or fundoscopy

  • If suspected aortic dissection: CT Aortogram

Hypertensive Urgency

1. Monitor BP and symptoms.

2. No medications needed immediately.

3. Regular medications for known hypertension cases.

4. Ambulatory emergency care unit (AECU) referral if suspicion of secondary cause of hypertension (Refer to section IV – Secondary).

5. Primary care referral once target organ damage assessment complete (Refer to section V - Primary).

Hypertensive Emergency

1. Continuous (arterial line) or frequent BP monitoring.

   • Initial Phase: Measure BP every 5-15 minutes in the initial hours

   • Stabilisation Phase: Measure BP every 30 minutes to an hour, then every 2-4 hours

2. Antihypertensive medications given intravenously (IV).

3. First-line IV medication choice from BMJ Best Practice (Refer to section VI - IV Antihypertensive Medications Choice) & section VII – IV Antihypertensive Medications Dose), that are available in FHFT:

• Labetalol

  • Accelerated (malignant) hypertension

  • Hypertensive encephalopathy

  • Intracranial haemorrhage

  • Acute ischaemic stroke

  • Aortic dissection

  • Pre-eclampsia and eclampsia

• Glyceryl trinitrate

  • Myocardial ischaemia/infarction

  • Left ventricular failure and/or pulmonary oedema

• Esmolol

  • Myocardial ischaemia/infarction

  • Aortic dissection

• Benzodiazepine

  • Hyperadrenergic state - Sympathomimetic drug use

• Phentolamine

  • Phaeochromocytoma

• Hydralazine

  • Pre-eclampsia and eclampsia

4. BP reduction target:

• Reduce mean arterial BP by no more than 25% within 1st hour.

• Then reduce to160/100-110mmHg in next 2-6 hours.

• Aim for normal BP over next 24-48 hours.

• Exceptions:

  • Ischaemic stroke

    • If BP >220/120 mmHg – lower the BP by 15% during the first 24 hours.

    • If BP <220/120 mmHg – close observation without direct intervention to reduce BP.

    • For thrombolysis candidates, reduce BP to <185/110 mmHg.

  • Severe pre-eclampsia, eclampsia, or phaeochromocytoma crisis

    • Reduce SBP to <140 mmHg in the 1st hour.

  • Aortic dissection

    • Reduce SBP to <120 mmHg in the first 20 minutes.

  • Spontaneous intracerebral haemorrhage

    • Acute lowering of SBP to a target of 140 mmHg

5. Medical referral for in-patient management

• Special care or ICU admission for severe cases with significant organ damage.

1. Regular BP monitoring.

2. Regular assessment and monitoring of target organ damage.

3. Adjust antihypertensive therapy based on BP readings and patient condition.

4. Switch from IV to oral antihypertensive medication as the condition stabilizes as per the recommendations (Refer to section VIII – Oral Antihypertensive Medications Recommendations).

5. First-line oral medication choice from NICE Guideline (Refer to section IX Oral Antihypertensive Medications Steps):

   a. ACE inhibitor or ARB

   * All with type 2 diabetes
   
   * All aged under 55 without type 2 diabetes
   
   * Prefer ARB if:
   
     - ACE inhibitor not tolerated
   
     - Black African or African–Caribbean family origin with type 2 diabetes
   

   b. Calcium-channel blocker (CCB)

   * All aged over 55 without type 2 diabetes
   
   * All Black African or African–Caribbean family origin without type 2 diabetes
   

   c. Thiazide-like diuretic

   * If CCB not tolerated
   
   * If evidence of heart failure
   

6. Assessment regarding secondary cause of hypertension, where suspected (Refer to section IV – Secondary Hypertension Assessment).

7. Primary care referral once target organ damage improves and the condition stabilizes (Refer to section V – Primary Care Referral).

Assess for underlying secondary causes if:

1. Age under 40 with hypertension

2. BP is unusually high and/or resistant to treatment

Secondary Causes:

1. Renal Disease: Renal artery stenosis, acute glomerulonephritis, and collagen vascular diseases.

2. Endocrine Disorders: Hyperaldosteronism, pheochromocytoma, thyroid disorders, Cushing's syndrome, and acromegaly.

3. Neurological Conditions: Head trauma, spinal cord injuries, and autonomic dysfunction.

4. Respiratory Issues: Obstructive Sleep Apnoea.

5. Immunologic Factors: Scleroderma and vasculitis.

6. Pregnancy-Related Causes: Preeclampsia and Eclampsia.

7. Vascular Conditions: Coarctation of the aorta.

8. Medication-Induced: NSAIDs, corticosteroids, oral contraceptives, and decongestants.

9. Substance Use: Chronic alcohol consumption, cocaine, and amphetamines.

Additional workup for secondary causes:

1. Renin & aldosterone levels, aldosterone:renin ratio

2. Serum and urine metadrenalines

3. Urine drug screen

1. Primary care review within 1 week for confirmation of diagnosis and long-term management.

   a. Advice home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM)

   b. Target BP 130/80mmHg (following hypertensive crisis).

   c. Monthly checks until the target BP is achieved.

   d. Then monitored every 3 to 6 months.

2. Communicate details of hospital treatment and BP readings to the primary care provider.

3. Educate and counsel on lifestyle modification

   a. Diet - Reduction of salt, caffeine and alcohol

   b. Exercise

   c. Smoking cessation

4. Emphasize the importance of medication adherence.

Fenoldopam, nifedipine, nitropruside, clevidipine, nicardipine are non-formulary, contact pharmacy for advice.

Sanders, M.L. and Suneja, M. (2024) 'Hypertensive emergencies', in BMJ Best Practice. London: BMJ Best Practice. Available at: https://bestpractice.bmj.com/topics/en-gb/27 (Accessed: 06 January 2025).

National Institute for Health and Care Excellence [NICE] (2023) Hypertension in adults: diagnosis and management. NG136. Available at: https://www.nice.org.uk/guidance/ng136 (Accessed: 06 January 2025).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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