Hypertensive emergency targets and drugs

The ESC 2024 hypertensive emergency table beside the ACC/AHA compelling conditions: aortic dissection (SBP < 120 and HR < 60 immediately, β-blocker before any vasodilator), acute coronary syndrome and acute cardiogenic pulmonary oedema (SBP < 140, nitroglycerin or labetalol; nitroprusside or nitroglycerin with a loop diuretic), malignant hypertension with or without TMA or AKI (MAP −20–25% over hours), hypertensive encephalopathy (MAP −20–25% immediately), phaeochromocytoma and cocaine or sympathomimetic crisis (phentolamine, benzodiazepines, no unopposed β-blockade) and severe pre-eclampsia, eclampsia or HELLP (treat at ≥ 160/110, target < 160/105, labetalol, nicardipine or hydralazine with magnesium sulphate), with ACOG, ISSHP and NICE obstetric recommendations. The entered BP and heart rate are turned into numeric targets, and a medication check strikes out drugs ruled out by home medications (enalaprilat on sacubitril/valsartan; nitroglycerin and nitroprusside after a PDE5 inhibitor).

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Compelling condition

Stroke and ICH: see the neurological BP targets

Current values

Optional: turns the target into numbers

Systolic

mmHg

Diastolic

mmHg

Heart rate

bpm

Revise the patient's medications

Ask before giving any drug in the ER

Acute aortic dissection

SBP < 120 mmHg and HR < 60 bpm

Immediately (ESC); within the first hour (ACC/AHA), usually within 20 min

Decision guide

First line

Esmolol 1–2 minLabetalol 5–10 min

Alternatives

Sodium nitroprusside Immediate (seconds)Nicardipine 5–15 minClevidipine 2–4 minNitroglycerin 1–5 min

With

IV opioid analgesia (pain drives catecholamines)
β-blocker intolerance: IV diltiazem or verapamil for rate control
Immediate surgical referral for type A

Avoid

Any vasodilator before the heart rate is controlled (reflex tachycardia raises aortic wall stress)
Hydralazine

Doses, onset, offset and pump rates: IV antihypertensive dosing.

Recommendations

ESC

Immediately: SBP < 120 mmHg and HR < 60 bpm
ESC 2024
Esmolol with nitroprusside, nitroglycerin or nicardipine; alternatives labetalol or metoprolol.
IV β-blocker titrated to HR ≤ 60 bpm and SBP 100–120 mmHg
IESC 2024 aorta
With analgesia; add a vasodilator once rate is controlled.

ACC/AHA

Aortic dissection: SBP < 120 mmHg during the first hour
IACC/AHA 2017
IV β-blocker to HR < 60 bpm and SBP < 120 mmHg
IACC/AHA 2022 aorta
β-blocker contraindicated: non-dihydropyridine calcium-channel blocker for rate control
ACC/AHA 2022 aorta
Do not start a vasodilator before rate control
ACC/AHA 2022 aorta

Hypertensive emergencies: timeframe, target and drugs

ESC 2024 hypertensive emergency table (with the ESC Council on Hypertension 2019 additions) beside the ACC/AHA 2017 compelling conditions

Condition	Timeframe	Target	First line	Alternatives
Acute aortic dissection	Immediately (ESC); within the first hour (ACC/AHA), usually within 20 min	SBP < 120 mmHg and HR < 60 bpm	Esmolol, Labetalol	Sodium nitroprusside, Nicardipine, Clevidipine, Nitroglycerin
Acute coronary syndrome	Immediately	SBP < 140 mmHg	Nitroglycerin, Labetalol	Urapidil, Esmolol, Clevidipine, Nicardipine
Acute cardiogenic pulmonary oedema	Immediately	SBP < 140 mmHg	Sodium nitroprusside, Nitroglycerin	Urapidil, Clevidipine, Enalaprilat
Malignant hypertension ± TMA or AKI	Over several hours	Lower MAP by 20–25%	Labetalol, Nicardipine	Sodium nitroprusside, Urapidil, Clevidipine
Hypertensive encephalopathy	Immediately	Lower MAP by 20–25%	Labetalol, Nicardipine	Sodium nitroprusside, Clevidipine, Urapidil
Phaeochromocytoma or cocaine / sympathomimetic crisis	Immediately; SBP < 140 within the first hour (ACC/AHA)	SBP < 140 mmHg (ACC/AHA); no fixed ESC target	Phentolamine	Sodium nitroprusside, Urapidil, Clevidipine, Nicardipine
Severe pre-eclampsia, eclampsia or HELLP	Within 30–60 min of confirmed severe BP	Treat at ≥ 160/110; target < 160/105 (ESC), 140–150/90–100 (ACOG)	Labetalol, Nicardipine, Hydralazine	—

References