Hypertensive emergencies

Last reviewed: 28 Dec 2022
Last updated: 24 Jun 2022



History and exam

Key diagnostic factors

  • blood pressure (BP) >180/120 mmHg
  • presence of risk factors
More key diagnostic factors

Other diagnostic factors

  • neurological symptoms
  • cardiac symptoms
  • abnormal cardiopulmonary examination
  • oliguria or polyuria
  • abnormal fundoscopic examination
  • abnormal neurological examination
Other diagnostic factors

Risk factors

  • inadequately treated hypertension
  • chronic kidney disease (CKD)
  • renal artery stenosis
  • renal transplant
  • endocrine disorders with known hypertensive effects
  • pregnancy
  • older age
  • black ethnicity
  • male sex
  • use of sympathomimetic drugs
  • pharmacotherapy with known hypertensive effect
  • obstructive sleep apnoea
  • vasculitis and connective tissue diseases
More risk factors

Diagnostic investigations

1st investigations to order

  • blood chemistry
  • FBC with smear
  • urinalysis with microscopy
  • ECG
  • chest x-ray
More 1st investigations to order

Investigations to consider

  • thyroid function tests
  • cardiac enzymes
  • brain natriuretic peptide (BNP)
  • urine toxicology screen
  • thoracic CT scan with contrast
  • transoesophageal echocardiography
  • renal ultrasound with Doppler
  • head CT without contrast
  • head MRI
  • plasma renin activity and aldosterone level
  • spot urine or plasma metadrenaline (metanephrine)
  • 24-hour urine free cortisol
  • sleep study
More investigations to consider

Treatment algorithm


accelerated (malignant) hypertension or hypertensive encephalopathy or intracranial haemorrhage

acute ischaemic stroke

myocardial ischaemia/infarction

left ventricular failure and/or pulmonary oedema

aortic dissection

acute kidney injury

hyperadrenergic state

severe hypertension in pregnancy (pre-eclampsia and eclampsia)



M. Lee Sanders, PhD, MD

Clinical Assistant Professor

Division of Nephrology

University of Iowa

Iowa City



MLS is an author of a reference cited in this topic.

Manish Suneja, MD, FASN, FACP

Clinical Professor

Division of Nephrology

University of Iowa

Iowa City



MS is an author of a reference cited in this topic.


Dr M. Lee Sanders and Dr Manish Suneja would like to gratefully acknowledge Dr Hector Ventura and Dr Madhavi T. Reddy, previous contributors to this topic.


HV declares that he has no competing interests. MTR is employed by Merck and owns stocks in Merck, and Johnson & Johnson.

Peer reviewers

Aparna Sundaram, DO, MBA, MPH

Physician Consultant

Preventive Medicine

Private Practice




AS declares that she has no competing interests.

Ethan Cumbler, MD

Assistant Professor

Department of Internal Medicine

University of Colorado Health Sciences Center




EC declares that he has no competing interests.

Michael Schachter, MB, BSc, FRCP

Department of Clinical Pharmacology

St Mary’s Hospital

Imperial College




MS declares that he has no competing interests.

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