HTN-Emergency

Hypertensive emergency + urgency · complete reference · all trials · full doses + brand names · Full Card

Symptoms / Associated Sx — Emergency

• Severe headache (worst of life or new character — posterior predominance); nausea/vomiting; altered mental status (confusion, agitation, somnolence); vision changes (blurring, scotomata, diplopia); fundoscopic: AV nicking and copper/silver wiring = chronic HTN; flame-shaped hemorrhages + papilledema = acute hypertensive retinopathy (true emergency)

• Chest pain ± diaphoresis: ACS (demand ischemia from ↑afterload) or aortic dissection (tearing quality + BP differential between arms) — most time-sensitive emergencies

• Acute dyspnea + orthopnea: hypertensive ADHF/APE (SBP often >180 in HFpEF); most responsive phenotype — dramatic improvement with IV NTG + furosemide (Lasix)

• Focal neurologic deficits: ischemic stroke (permissive HTN required unless tPA eligible); hemorrhagic stroke (target SBP <140 within 1h per ATACH-2); PRES (posterior reversible encephalopathy syndrome — AMS + seizures + visual disturbance + MRI: T2/FLAIR posterior leukoencephalopathy)

• Hematuria + azotemia + RBC casts on UA: hypertensive nephropathy (microangiopathic hemolytic anemia — MAHA; schistocytes on smear; ↑LDH + ↓haptoglobin)

• Pheochromocytoma crisis: paroxysmal hypertensive surges + diaphoresis + headache + palpitations + pallor; precipitated by tumor manipulation, anesthesia, contrast agents, certain medications; 24h urine metanephrines + catecholamines diagnostic

• Pregnancy-associated: preeclampsia (SBP ≥140 or DBP ≥90 after 20 weeks + proteinuria + features of severe range: SBP ≥160 or DBP ≥110 + headache + visual changes + RUQ pain); eclampsia (preeclampsia + seizures); HELLP syndrome (hemolysis + ↑LFTs + ↓platelets)

Neg

• Pt denies any end-organ symptoms (headache, vision changes, CP, dyspnea, focal neuro deficits, AMS, oliguria, hematuria) despite SBP ≥180 mmHg — argues against hypertensive emergency (this is hypertensive urgency; IV antihypertensives not required; oral agents + PO restart; no ICU admission; aggressive IV lowering in urgency causes iatrogenic ischemic stroke from loss of cerebrovascular autoregulation)

• Pt denies tearing/ripping quality pain radiating between shoulder blades with unequal BP between arms (>20 mmHg differential) or widened mediastinum on CXR — argues against aortic dissection (aortic dissection requires anti-impulse therapy with esmolol [Brevibloc] first, NOT pure vasodilators; pure vasodilator alone → reflex tachycardia → ↑dP/dt → propagation of dissection; CTA chest/abdomen/pelvis BEFORE any vasodilator if dissection suspected)

• Pt denies new focal neurologic deficit (hemiplegia, aphasia, facial droop, hemianopia) — argues against ischemic or hemorrhagic stroke requiring modified BP target (ischemic stroke without tPA: permissive HTN ≤220/120 to maintain penumbra perfusion; ischemic stroke pre-tPA: lower to <185/110 and NEVER below 160 during tPA administration)

• Pt denies paroxysmal hypertensive surges + diaphoresis + pallor + headache without medication trigger — argues against pheochromocytoma crisis (pheo: alpha-blockade with phentolamine [Regitine] FIRST; NEVER BB first without prior alpha-blockade → paradoxical hypertension from unopposed alpha stimulation → hypertensive crisis worsening)

Social History (SHx)

• Known HTN duration, prior BP readings (highest recorded — helps contextualize current severity); antihypertensive regimen adherence (medication cost, side effects, forgetfulness — non-adherence is the most common cause); missed doses (especially clonidine [Catapres] — rebound crisis; BB — rebound ischemia)

• Cocaine/amphetamines/sympathomimetics (paroxysmal HTN + tachycardia + diaphoresis + chest pain); OSA (untreated — chronic sympathetic activation + ↑aldosterone); CKD; pregnancy status (all reproductive-age women); family history hypertension, pheochromocytoma (MEN2, VHL), renal artery stenosis (FMD — young women); sodium intake and dietary habits

Main Etiology

• Medication non-adherence (~75% of hypertensive emergencies): medication cost, side effects, forgetfulness, loss of follow-up; most common and most preventable cause

• Secondary HTN causes (rule out in refractory or early-onset HTN): primary hyperaldosteronism (aldosteronoma — hypokalemia + non-suppressible aldosterone; plasma aldosterone-to-renin ratio >30 + CT adrenals); renovascular HTN (renal artery stenosis — fibromuscular dysplasia in young women, atherosclerosis in older patients; MR renal angiography or duplex US); pheochromocytoma (paroxysmal HTN — 24h urine metanephrines + catecholamines; CT/MRI adrenals; MIBG scan); obstructive sleep apnea; chronic kidney disease (↑renin-angiotensin activation); Cushing syndrome (↑cortisol → Na retention)

• Drug-induced: cocaine, amphetamines, sympathomimetics (decongestants), clonidine [Catapres] withdrawal, BB withdrawal, MAOI + tyramine interaction, NSAIDs (↑Na/H2O retention), erythropoietin, calcineurin inhibitors (tacrolimus [Prograf]/cyclosporine [Sandimmune])

• Pregnancy-associated: preeclampsia, eclampsia, HELLP syndrome; gestational HTN (no proteinuria); chronic HTN worsening in pregnancy

RF

• Modifiable: medication non-adherence (most important — address at every encounter), high Na+ intake (>2g/day), obesity, physical inactivity, ETOH (>3 drinks/day), cocaine/stimulants, OSA (untreated), NSAIDs (↑Na retention + ↑BP), high-dose oral contraceptives

• Non-modifiable: older age, Black race (↑prevalence + severity of HTN; salt-sensitive; thiazide + CCB preferred), CKD (↑renin-angiotensin), family history, prior hypertensive emergency

• Secondary HTN screen: age <30 with severe HTN, refractory HTN (>3 agents at max doses), hypokalemia (aldosteronism), paroxysmal surges (pheochromocytoma), abdominal bruit (RAS), truncal obesity + striae + moon facies (Cushing)

Data

• BP bilateral both arms ×2 readings 5 min apart (use correct cuff size: too small → falsely high; measure both arms: >20 mmHg differential = dissection until proven otherwise; bilateral readings confirm accuracy; document exact numbers — not "elevated")

• ECG (LVH: Sokolow-Lyon ≥35 mm [SV1+RV5]; LV strain pattern [ST↓ + TWI lateral leads] = chronic severe HTN; acute ST changes = ACS trigger; new LBBB; AV block from hypertensive CM)

• BMP (Cr + BUN — hypertensive nephropathy; Cr rise is primary end-organ marker; BUN/Cr ratio >20 = prerenal from ↓renal perfusion; K+ — ↓K+ suggests hyperaldosteronism or diuretic use; Na+ — hypernatremia in renovascular HTN; CO2 — metabolic alkalosis in hyperaldosteronism)

• UA with microscopy (RBC casts = hypertensive nephropathy/glomerulonephritis — emergency; proteinuria >300 mg/dL = preeclampsia threshold; granular casts = acute tubular injury; 24h urine protein if proteinuria found)

• Troponin I/T (ACS trigger from ↑afterload → ↑myocardial O2 demand; demand ischemia; elevated troponin in hypertensive ADHF + APE from wall stress; guides antiplatelet/anticoag decision)

• CXR portable (widened mediastinum >8 cm — dissection; pulmonary edema — ADHF/APE; cardiomegaly — LVH from chronic HTN; pleural effusions)

• Head CT non-contrast STAT (hemorrhagic stroke — hyperdense signal; exclude hemorrhage before any thrombolytic consideration; hypertensive encephalopathy — usually negative on CT; MRI more sensitive for PRES: T2/FLAIR posterior leukoencephalopathy in occipital/parietal regions)

• CTA chest/abdomen/pelvis (aortic dissection: if tearing pain + BP differential → CTA BEFORE any vasodilator; true lumen vs false lumen; extent of dissection; branch vessel involvement; pericardial effusion = hemopericardium)

• Fundoscopic exam (AV nicking + copper/silver wiring = chronic hypertensive changes; flame-shaped hemorrhages + cotton wool spots + papilledema = acute hypertensive retinopathy → true emergency regardless of BP level)

• CBC + peripheral smear (schistocytes → microangiopathic hemolytic anemia [MAHA] in hypertensive nephropathy or TTP; ↓platelets in HELLP; ↑WBC in pheochromocytoma)

• Urine + serum pregnancy test (all reproductive-age women; preeclampsia/eclampsia management fundamentally different; MgSO4 + delivery)

• 24h urine metanephrines + catecholamines (if pheochromocytoma suspected) (paroxysmal HTN + diaphoresis + pallor + headache; draw BEFORE alpha-blockade if possible; CT/MRI adrenals after biochemical confirmation)

• Plasma aldosterone-to-renin ratio (if hyperaldosteronism suspected) (ratio >30 + plasma aldosterone >15 ng/dL = positive screen; confirm with saline suppression test; CT adrenals + adrenal vein sampling; adrenal adenoma → unilateral adrenalectomy curative)

DDx

Hypertensive urgency (severe BP without end-organ damage — oral agents; no IV; no ICU; aggressive IV lowering causes ischemic stroke from autoregulation failure) · Aortic dissection (tearing + BP differential — CTA BEFORE vasodilators; esmolol [Brevibloc] + nitroprusside [Nipride]; never pure vasodilator alone) · Hypertensive encephalopathy/PRES (AMS + seizures + visual + MRI posterior leukoencephalopathy — nicardipine [Cardene] or labetalol [Trandate]) · Ischemic stroke (focal neuro deficit — permissive HTN ≤220 unless tPA eligible; SBP <185 for tPA; never below 160 during infusion) · Hemorrhagic stroke/ICH (hyperdense signal on CT — SBP target <140 within 1h per ATACH-2 using nicardipine [Cardene]) · Pheochromocytoma crisis (paroxysmal + diaphoresis + pallor — phentolamine [Regitine] 5 mg IV; alpha FIRST then BB) · Preeclampsia/eclampsia (pregnancy + proteinuria + seizures — MgSO4 + labetalol [Trandate] + delivery) · ADHF/APE (SBP >160 + dyspnea + pulm edema — NTG IV + Lasix IV + NIPPV)

Home Meds

• Restart all outpatient antihypertensives PO (most common cause of emergency is non-adherence; restarting home medications is cornerstone of treatment alongside IV agents); do NOT abruptly restart high-dose clonidine (Catapres) IV (rebound risk when discontinued; restart PO at home dose)

• Hold: NSAIDs (ibuprofen [Advil]/naproxen [Aleve]/celecoxib [Celebrex] — ↑Na retention → ↑BP; avoid indefinitely); calcineurin inhibitors (tacrolimus [Prograf]/cyclosporine [Sandimmune]) — review dose; erythropoietin (Epogen/Procrit) — ↑BP in CKD; oral contraceptives (↑aldosterone → ↑Na retention)

• Avoid hydralazine (Apresoline) in: aortic dissection (↑reflex tachycardia → ↑shear stress → propagation); ACS (↑reflex tachycardia → ↑myocardial O2 demand); prefer nicardipine (Cardene) or labetalol (Trandate) in these settings

• Avoid BB alone in pheochromocytoma without prior alpha-blockade (unopposed alpha → paradoxical HTN worsening)

Plan — Emergency

• Critical principle — identify the end-organ, then choose the drug: no single "hypertensive emergency drug" — each end-organ requires a specific agent; wrong drug = worse outcome; the BP target and rate of lowering also differ by end-organ

• Standard BP target: MAP↓ 20–25% in first hour; then 160/100–110 over next 2–6h; then 135/85 over next 24–48h; do NOT normalize BP to <140 in first 24h (loss of cerebrovascular + coronary autoregulation → ischemia); exception = aortic dissection (SBP <120 as fast as possible)

• IV agents by end-organ damage:

  • Hypertensive ADHF/APE (most responsive): nitroglycerin (NTG/Nitro-Bid) 5–10 mcg/min IV → titrate to max 200 mcg/min (↓preload + afterload; tolerance at 24–48h; hold SBP <90 or RV MI); furosemide (Lasix) 40–80 mg IV simultaneously; NIPPV BiPAP; target MAP↓ 25% in 1h

  • Aortic dissection: esmolol (Brevibloc) 500 mcg/kg IV bolus → 50–200 mcg/kg/min infusion (FIRST — anti-impulse: ↓HR to <60 + ↓dP/dt); THEN add nitroprusside (Nipride) 0.3–10 mcg/kg/min if SBP >120; target SBP <120 + HR <60 within 20 minutes; NEVER start with pure vasodilator alone (reflex tachycardia → ↑shear force → extension); cyanide toxicity with nitroprusside (Nipride) >72h or high doses — check thiocyanate level if prolonged use; OR labetalol (Trandate) 20 mg IV → 80 mg q10 min (both alpha + beta block; easier to use than esmolol [Brevibloc] + nitroprusside [Nipride] combination)

  • Hypertensive encephalopathy/PRES: nicardipine (Cardene) 5 mg/hr → titrate by 2.5 mg/hr q5–15 min (max 15 mg/hr; smooth predictable titration; no reflex tachycardia; preferred in neurologic emergency); OR labetalol (Trandate) 20 mg IV q10–15 min (max 300 mg/24h) → infusion 2 mg/min; target MAP↓ 20–25% in first hour; MRI brain for PRES diagnosis

  • Ischemic stroke (non-tPA candidate): permissive HTN — do NOT treat unless SBP >220 or DBP >120 (brain depends on elevated BP to perfuse ischemic penumbra; lowering BP = extending stroke); if treatment needed → labetalol (Trandate) 10 mg IV or nicardipine (Cardene) 5 mg/hr; target SBP <220 — NOT normalized

  • Ischemic stroke (tPA candidate): lower SBP to <185/110 before tPA administration; nicardipine (Cardene) 5–15 mg/hr or labetalol (Trandate) 10–20 mg IV; maintain SBP 140–180 during and 24h after tPA; NEVER SBP <160 during tPA (hemorrhagic transformation)

  • Hemorrhagic stroke (ICH): nicardipine (Cardene) 5–15 mg/hr IV; target SBP <140 within 1h (ATACH-2 2016, NEJM: intensive SBP <140 vs standard <180; no mortality benefit but reduced hematoma expansion; SBP <130 harmful); avoid SBP <130

  • Hypertensive nephropathy/MAHA: nicardipine (Cardene) 5–15 mg/hr or labetalol (Trandate); AVOID ACEi/ARB acutely in bilateral renal artery stenosis (↑K+ + ↑Cr acutely; safe to start after RAS excluded or unilateral); assess for TTP (ADAMTS13 level) if MAHA + thrombocytopenia

  • ACS + HTN emergency: nitroglycerin (NTG/Nitro-Bid) IV 5–200 mcg/min + IV metoprolol tartrate (Lopressor) 5 mg q5 min ×3; avoid nitroprusside (Nipride) in ACS (coronary steal phenomenon → ↑ischemia); aspirin (Bayer) 325 mg + P2Y12 loading per ACS protocol

  • Pheochromocytoma crisis: phentolamine (Regitine) 5 mg IV → repeat q5 min to SBP target (pure alpha-1 + alpha-2 blockade; no reflex tachycardia from alpha-2 blockade); NEVER BB first without prior alpha-blockade (unopposed alpha → paradoxical BP surge); after adequate alpha-blockade established → propranolol (Inderal) 1 mg IV or esmolol (Brevibloc) for rate control; phenoxybenzamine (Dibenzyline) 10–40 mg PO BID for chronic blockade pre-surgery

  • Preeclampsia/eclampsia: MgSO4 4–6 g IV over 20 min → 1–2 g/hr maintenance (seizure prophylaxis + treatment; monitor Mg level: therapeutic 4–7 mEq/L; toxic >8 → respiratory arrest → calcium gluconate 1 g IV antidote); labetalol (Trandate) 20 mg IV → double q30 min (max 300 mg) or hydralazine (Apresoline) 5–10 mg IV q20–30 min for SBP ≥160; target SBP 140–150, DBP 90–100 (avoid SBP <140 — placental hypoperfusion); nifedipine (Procardia) XL 10–30 mg PO (safe in pregnancy); DEFINITIVE TREATMENT = delivery; obstetrics team essential

• Arterial line placement: recommended for aortic dissection, hypertensive encephalopathy, and any end-organ emergency requiring continuous real-time BP titration; radial artery preferred; allows simultaneous blood sampling

• ICU/step-down: ICU for aortic dissection + encephalopathy + hemorrhagic stroke + pheochromocytoma crisis; step-down/monitored bed for ADHF/APE + hypertensive nephropathy

• Transition to oral agents: once BP controlled and end-organ stable (typically 12–24h): amlodipine (Norvasc) 5–10 mg PO daily (preferred for Black patients and elderly); lisinopril (Zestril) 5–40 mg PO daily (preferred for CKD + DM + HF); losartan (Cozaar) 25–100 mg PO daily if ACEi intolerant; hydrochlorothiazide (Microzide) 12.5–25 mg PO daily or chlorthalidone (Thalitone) 12.5–25 mg PO daily (chlorthalidone preferred — longer half-life, ↑CV outcomes per ALLHAT); carvedilol (Coreg) or metoprolol succinate (Toprol-XL) if HF, post-MI, tachycardia

• Secondary HTN workup before discharge (if indicated): plasma aldosterone-to-renin ratio (screen for primary hyperaldosteronism — ≥2 of: hypokalemia, severe/refractory HTN, adrenal incidentaloma, onset <30 years, family history hyperaldosteronism); 24h urine metanephrines + catecholamines (pheochromocytoma screen); renal artery duplex US or CTA renal arteries (renovascular HTN — young women with severe HTN or smoking + atherosclerosis); cortisol (Cushing — truncal obesity + striae + moon facies + proximal weakness + diabetes)

• PT/OT eval and treat — bed rest until BP controlled and end-organ stable; early mobilization once hemodynamically stable; occupational therapy for stroke/encephalopathy sequelae; fall risk assessment with antihypertensives

• Trend daily: BP q15–30 min until at target → q1h → q4h once stable; BMP (Cr/K+ — hypertensive nephropathy + ACEi/ARB monitoring); UA daily (RBC casts resolution); CBC + smear (MAHA resolution); troponin if ACS component; neuro checks q1–2h (encephalopathy/stroke); fundoscopy improvement; urine output; fever curve

• Escalation triggers: PRES + seizures → IV labetalol (Trandate) + lorazepam (Ativan) 2–4 mg IV; MRI brain; neurology consult · aortic dissection confirmed → cardiac surgery consult immediately (Type A = emergent surgery; Type B = medical anti-impulse therapy ± TEVAR) · eclampsia → MgSO4 + immediate delivery + obstetrics + MFM · pheochromocytoma crisis refractory → phentolamine (Regitine) escalation + continuous infusion + endocrinology + surgery · AKI worsening (Cr doubling or oliguria) → nephrology + consider dialysis if refractory; withhold ACEi/ARB · hemorrhagic stroke + hematoma expansion → neurosurgery · refractory hypertension despite 3 IV agents → consider nitroprusside (Nipride) arterial line monitoring + rule out secondary causes urgently

• Discharge: 2–3 oral antihypertensive agents (amlodipine [Norvasc] 5–10 mg + lisinopril [Zestril] 5–40 mg or losartan [Cozaar] 25–100 mg + chlorthalidone [Thalitone] 12.5–25 mg); address adherence barriers (medication cost assistance, simplified regimen, pill boxes, auto-refill pharmacy); home BP monitor (BP ≥150/95 → call provider same day); home BP log (record ×2 daily morning and evening); PCP f/u 1 week; cardiology/nephrology f/u if indicated; secondary HTN workup if not completed; lifestyle: DASH diet (<2g Na+/day), weight loss, aerobic exercise 150 min/week, ETOH ≤1 drink/day, smoking cessation; return precautions: severe headache + vision changes + CP + focal neuro deficit + AMS → 911 immediately

⚠ Red Flags

• Too-rapid BP lowering in hypertensive emergency → cerebral autoregulation failure → ischemic stroke; brain, heart, and kidneys autoregulate BP over a range that is shifted upward in chronic hypertensives; acute normalization of BP in a chronically hypertensive patient = iatrogenic ischemia; target MAP↓ 20–25% in first hour, not to normal BP

• Treating hypertensive urgency (severe BP without end-organ damage) with IV agents → same autoregulation failure risk; urgency = oral agents + PO optimization + PCP f/u; no IV required; aggressive IV treatment of urgency causes more harm than good

• Pure vasodilator in aortic dissection without prior beta-blockade → reflex tachycardia → ↑dP/dt (rate of pressure rise) → ↑shear force → proximal extension → hemopericardium → cardiac tamponade → death; always esmolol (Brevibloc) FIRST, then add nitroprusside (Nipride) for refractory BP

• BB alone in pheochromocytoma crisis → unopposed alpha-adrenergic stimulation → severe paradoxical HTN surge → hypertensive crisis worsening; always alpha-block first with phentolamine (Regitine); THEN add BB for rate; never reverse this order

• Nitroprusside (Nipride) infusion >72h or high-dose → cyanide toxicity (lactic acidosis + AMS + seizures); check thiocyanate level after 72h; limit to shortest necessary duration; hydroxocobalamin (Cyanokit) is antidote

• NTG in suspected RV MI complicating inferior STEMI + hypertension → ↓preload → hemodynamic collapse; check V4R before NTG in any inferior STEMI patient presenting with hypertension; always obtain right-sided leads

• MgSO4 toxicity in preeclampsia/eclampsia (Mg level >8 mEq/L → respiratory depression → arrest): monitor DTRs (first to go at Mg 7–10 mEq/L), respiratory rate (q1h), urine output (>25 mL/hr required for excretion); antidote = calcium gluconate 1 g IV over 5–10 min; always have at bedside

Senior IM Resident Pearls

• Emergency vs urgency — the only distinction that matters: hypertensive EMERGENCY = severe BP + acute end-organ damage (brain, heart, kidneys, aorta, eyes, fetus); hypertensive URGENCY = severe BP without end-organ damage; the BP number alone NEVER defines an emergency; the organ damage defines it; a patient with SBP 210 + no symptoms = urgency (oral agents, no ICU); a patient with SBP 170 + papilledema + AMS = emergency (IV agents, ICU)

• Drug-to-end-organ matching — the most important clinical decision in HTN emergency: ADHF/APE → NTG IV; aortic dissection → esmolol [Brevibloc] then nitroprusside [Nipride]; ischemic stroke non-tPA → permissive HTN ≤220; ischemic stroke pre-tPA → <185; ICH → nicardipine [Cardene] SBP <140; pheochromocytoma → phentolamine [Regitine] (alpha first); preeclampsia → MgSO4 + labetalol [Trandate]; nicardipine [Cardene] is the most versatile IV agent and appropriate for most non-dissection, non-cardiac HTN emergencies

• Aortic dissection — anti-impulse therapy before vasodilator: esmolol (Brevibloc) reduces HR to <60 bpm AND ↓dP/dt (rate of pressure rise = shear force driver) BEFORE any vasodilator; pure vasodilator → reflex tachycardia → ↑shear → propagation; combination esmolol + nitroprusside (Nipride) is standard; labetalol (Trandate) alone is acceptable (both alpha + beta block); target SBP <120 + HR <60 within 20 minutes = fastest target of any HTN emergency

• Pheochromocytoma — alpha first, always: BB without alpha-blockade → blocks beta-mediated vasodilation → unopposed alpha → paradoxical BP surge; phentolamine (Regitine) 5 mg IV first → then propranolol (Inderal) or esmolol (Brevibloc) for rate; phenoxybenzamine (Dibenzyline) 10–40 mg PO BID for 7–14 days pre-operatively; this reversal (BB before alpha) is an examined and deadly error

• Permissive hypertension in ischemic stroke: penumbra (salvageable ischemic tissue) relies on elevated BP for perfusion (pressure-passive flow in zone of autoregulation failure); lowering BP in non-tPA ischemic stroke → extend infarct → worse outcome; ONLY lower if SBP >220 or DBP >120, or if tPA eligible (target <185); during tPA: maintain SBP 140–180, NEVER below 160 (hemorrhagic transformation)

• MgSO4 safety in preeclampsia/eclampsia — therapeutic vs toxic window: therapeutic Mg level 4–7 mEq/L; ↓DTRs at 7 mEq/L; respiratory depression at 10–13 mEq/L; cardiac arrest at >15 mEq/L; monitor DTRs hourly, respiratory rate ≥12, UO >25 mL/hr; antidote calcium gluconate 1 g IV — keep at bedside; reduce dose in CKD (renal excretion)

• ATACH-2 (2016, NEJM) — ICH BP target: intensive SBP <140 vs standard <180 within 1h → no ↓death/disability at 90 days; intensive group had ↑renal AEs; current target SBP <140 for hematoma expansion prevention but avoid <130; use nicardipine (Cardene) for smooth predictable titration in ICH

• Common mistake — aggressive IV lowering of hypertensive urgency: urgency (severe BP + no end-organ damage) treated with IV labetalol, IV nicardipine, or IV hydralazine → BP drops rapidly → loss of cerebrovascular autoregulation → ischemic stroke in a previously well patient; urgency = restart PO antihypertensives + PCP f/u in 3–7 days; the most common iatrogenic complication of hypertension management in the hospital