Malignant Hypertension Guidelines

Updated: May 26, 2020
  • Author: John D Bisognano, MD, PhD, FACP, FACC; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Guidelines Summary

The 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults characterizes hypertensive crises as severe blood pressure (BP) elevations (>180/120 mm Hg) associated with acute end-organ damage and characterizes such elevations of blood pressure without target organ issues as “markedly elevated BP.”

Overly aggressive treatment of severe uncomplicated hypertensive urgency can lead to cumulative effects causing hypotension. Early triage is required to determine which patients with acute hypertension are exhibiting symptoms of end-organ damage and require immediate intravenous parenteral antihypertensive therapy. [13]

The 2017 ACC/AHA guideline recommends admission to an intensive care unit and parenteral administration of an appropriate agent.

For patients with compelling indications such as aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma, systolic should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection. In others with hypertensive emergencies, systolic should be reduced by no more than 25% within the first hour then, if stable, to 160/100 mm Hg within the next 2 to 6 hours, and then cautiously to normal during the following 24-48 hours.

Several parenteral and oral agents are recommended to treat hypertensive emergencies, such as nitroprusside sodium, hydralazine, nicardipine, fenoldopam, nitroglycerin, and enalaprilat. Other agents that may be used include labetalol, esmolol, and phentolamine. Short-acting nifedipine should not be considered for the initial treatment of this condition, because of the risk of rapid, unpredictable hypotension and the possibility of precipitating ischemic events. Once the patient’s condition is stabilized, BP may be gradually reduced over the next 24-48 hours. [13]

The 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines provided similar recommendations. [17]

In 2013, the American College of Emergency Physicians (ACEP) released an update of its 2006 guidelines for hypertension in the emergency department (ED), which are focused on treating hypertensive urgency. The recommendations included the following [18] :

  • In ED patients with asymptomatic markedly elevated BP, routine screening for acute target-organ injury (eg, serum creatinine, urinalysis, electrocardiography [ECG]) is not required.
  • In select patient populations (eg, those with poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission)
  • In patients with asymptomatic markedly elevated BP, routine ED medical intervention is not required
  • In select patient populations (eg, those with poor follow-up), emergency physicians may treat markedly elevated BP in the ED and/or initiate therapy for long-term control (consensus recommendation)
  • Patients with asymptomatic markedly elevated BP should be referred for outpatient follow-up (consensus recommendation)