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Evaluation and treatment of hypertensive emergencies in adults

William J Elliott, MD, PhD
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
Section Editors
George L Bakris, MD
Norman M Kaplan, MD
Deputy Editor
John P Forman, MD, MSc


Most patients with significantly elevated blood pressure (systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg) have no acute, end-organ injury (so called severe asymptomatic hypertension). Although some propose relatively rapid initiation of antihypertensive therapy in this setting, there may be more risk than benefit from such an aggressive regimen. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)

By contrast, some patients with significantly elevated blood pressure have signs or symptoms of acute, ongoing target-organ damage. Such patients have a hypertensive emergency. Hypertensive emergencies can develop in patients with or without preexisting chronic hypertension [1,2]. Often, the diastolic pressure is ≥120 mmHg, but there is no specific threshold since individuals who develop an acute rise in blood pressure can develop symptoms if the previous pressure was normal (such as in a pregnant woman who develops eclampsia or a young adult who develops acute glomerulonephritis).

The term "malignant hypertension" entered the medical lexicon in 1928 because, at that time, patients with this condition had a prognosis that was similar to patients with many cancers. However, antihypertensive therapies that can quickly and safely lower blood pressure have improved outcomes [3] and, therefore, the term is now used only by billing and coding personnel.


The history and physical examination in patients presenting with a severely elevated blood pressure (or an acute rise in blood pressure over a previously normal baseline, even if the presenting pressure is <180/120 mmHg) should determine whether or not any of the following are present [4]:

Acute head injury or trauma

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Literature review current through: Nov 2017. | This topic last updated: Aug 16, 2016.
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