BP ≥180 and/or diastolic ≥120 + end-organ damage (BRAIN/HEART/KIDNEY)

Sx: Neurologic: Severe headache, confusion, altered mental status, visual disturbances, Cardiovascular : Chest pain, dyspnea, pulmonary edema, palpitations, and signs of heart failure. Renal Oliguria, hematuria, and azotemia suggest acute kidney injury

HX: HTN,CKD,hyperaldosteronism,Pheochromocytoma,Cushing,Thyroid disease, Steroids use, Renal artery stenosis, Substance use (cocaine,amphetamine),alcohol use (and withdrawal),OSA

W/U: CBC, RFP, Mag, trop, UA, UDS , (consider: TSH,plasma metanephrines)

CXR, ECG, CTH if nurological sx, CTA if concern dissection,Echo (HF?)

Causes: poorly controlled chronic hypertension, nonadherence or abrupt withdrawal of antihypertensives), CKD, secondary hypertension (e.g., pheochromocytoma, Cushing syndrome, hyperaldosteronism), stimulant or alcohol use (cocaine, amphetamines), nonadherence or abrupt withdrawal of antihypertensives), and pregnancy-related conditions such as preeclampsia or eclampsia.)

Complications: acute coronary syndrome, aortic dissection, endocrine crises (pheochromocytoma, thyroid storm), and preeclampsia/eclampsia

Home meeds

Targets

• general: blood pressure should be decreased by 20-25% during the first hour and to 160/100 mm Hg by 2-6 hours

• Aortic dissection SBP <120 mmHg, HR <60 within 20-60 minutes,

• ICH (hemorrhagic stroke) reduction to 140-150 mm Hg within 1 hour

• Ischemic stroke + tPA SBP <185/<110 pre-tPA and <180/<105 x24h

• ACS require systolic BP reduction to <140 mm Hg within 1 hour and diastolic BP >60 mm Hg

• Ischemic stroke (no tPA) only if SBP >220 or DBP >120 Gradual 15% reduction in 24 hr

• Acute pulmonary edema SBP <160-180 mmHg Rapid (minutes-hours)

• Severe preeclampsia/eclampsia <160/110

decrease BP by 20-25% first hour and to 160/100 2-6 hours unless aortic dissection , ICH , ischmic stroke or ACS)

10 mg IV Labetalol Recheck BP in about 10 min, If still severely elevated → repeat 20 mg → 40 mg → 80 mg every 10 minutes max 300 mg daily -> think ICU and Nicardipine (5 mg/hr IV infusion Increase by 2.5 mg/hr every 5–15 min Max 15 mg/hr) (( avoid BB in HR<60 or decompensated HF))

HR <60 but no pulmonary edema, Hydralazine 5 mg IV once Reassess BP in 20–30 min, Repeat 10 mg q20–40 min PRN , if still high think ICU and Nicardipine gtt

Acute pulmonary edema / CHF + severe HTN IV Nitroglycerin Start 5–10 mcg/min IV infusion Increase every 3–5 min 20 → 40 → 80 mcg/min etc depending on BP/symptoms

IV Labetalol, nicardipine, and nitroprusside

• Nicardipine for most (encephalopathy, stroke, renal failure, perioperative)

• labetalol most also Cocaine/amphetamine toxicity, with high HR Avoid if: Acute HF, bradycardia, asthma/COPD, acute stroke

• nitroglycerin ACS/AHF/Pulm edema -> add IV labetalol/esmolol resuce HR too or cardene, if pulm edema lasix first, Venous > arterial dilation → ↓preload rapidly (lung fluid offload); coronary vasodilation in ACS Avoid: Hypotension (SBP <90), RV infarct, recent PDE5 inhibitors (Viagra), hypertrophic cardiomyopathy. Add labetalol/esmolol (HR control) or nicardipine (arterial dilation) if needed; lasix first in pulmonary edema.

• esmolol: aortic dissection thyroid storm, Avoid if: Acute HF, bradycardia, asthma. ultra-short half-life (9 minutes) and rapid onset (2-10 minutes) so rappid titration

• Nitroprusside for: Refractory HTN emergencies, (rarely first-line now). Avoid: Prolonged use (>48h, cyanide toxicity), liver/renal failure, Leber's optic atrophy; requires thiocyanate monitoring.

• lasic

• Furosemide pulmonary edema secondary to hypertensive emergency.

After 24-48 hours of IV therapy, oral antihypertensive medication can be slowly instituted and IV medication tapered

• Nicardipine IV → transition to amlodipine 5–10 mg daily once BP is stable.renal-protective, easy titration, minimal reflex tachycardia. Avoid: Acute HF (negative inotrope), advanced aortic stenosis

• Labetalol IV → transition to oral labetalol 200–400 mg BID when hemodynamically stable. Alpha+beta-blocker → smooth BP/HR control without vasodilation (no reflex tachy); bolus-friendly

• Esmolol IV → transition to metoprolol succinate 50–100 mg daily after rate/BP control is achieved.

• V nitroglycerin (GTN) → transition to hydralazine 25 mg TID (or another oral vasodilator)

avoid abrupt stop IV med —gradual overlap with oral meds

Hydralazine should be avoided in hypertensive encephalopathy due to unpredictable effects on cerebral blood flow

Aortic dissection: Esmolol → add nitroprusside.

Pulmonary edema: Nitroglycerin 5-10 mcg/min ↑5-10 mcg/min.

ACS: Nitroglycerin ± beta-blocker.

Pheo: Phentolamine 1-5 mg IV.

Resume home meds if appropriate (provides baseline control).

BP (systolic pressure ≥180 mm Hg and/or diastolic pressure ≥120 mm Hg) without end-organ damage

non symptomatic

-HX: HTN,CKD,hyperaldosteronism,Pheochromocytoma,Cushing,Thyroid disease, Steroids use, Renal artery stenosis, Substance use (cocaine,amphetamine),alcohol use (and withdrawal),OSA

W/U: CBC, RFP, Mag, trop, UA, UDS , (consider: TSH,plasma metanephrines)

Home meeds

start home HTN meds if possible

Amlodipine 5 mg PO daily Onset: ~6–8 hours

Hydralazine 10–25 mg PO PRN Onset: ~20–30 min

tele

daily labs