Hypertensive Crisis

Hypertensive crisis is the term for blood pressure that rises to very high levels, usually a systolic pressure (top number) of 180 mmHg or higher, or a diastolic pressure (bottom number) of 110 mmHg or higher. Hypertensive crisis is part of hypertension, which is covered on the Hypertension page. The 2024 ESC and 2023 ESH guidelines distinguish two situations that are managed differently, so the next steps are decided by the doctor's assessment, not by the blood pressure reading alone.

Hypertensive Emergency

A hypertensive emergency occurs when very high blood pressure comes with new or ongoing organ damage. Examples include stroke, heart attack, acute heart failure with fluid in the lungs, a tear in the wall of the aorta, brain dysfunction caused by high pressure (hypertensive encephalopathy), acute kidney failure, or severe preeclampsia in pregnancy. This condition needs care in the emergency room or intensive care unit, with medicines given through an IV and close monitoring.

Severe Hypertension Without Acute Organ Damage

When blood pressure is very high but tests find no new organ damage, the condition used to be called hypertensive urgency. Current guidelines do not recommend lowering blood pressure rapidly in this situation. It is usually enough to restart or adjust oral medicines, then have a follow-up visit within a few days. Lowering blood pressure too quickly can actually reduce blood flow to the brain, heart, and kidneys.

Malignant Hypertension

Malignant hypertension is a form of hypertensive emergency with damage to small blood vessels that can be seen in the retina of the eye, in the form of bleeding, spots, or swelling of the optic nerve. It often comes with declining kidney function and damage to blood cells, so it needs treatment in the hospital.

Why It Happens

Hypertensive crisis often occurs in people with hypertension whose blood pressure is not yet under control or who have stopped taking their medicine. In some people, a crisis is the first sign of hypertension that had never been detected, or a sign of another cause such as kidney disease or a hormonal disorder. Severe pain, anxiety, or panic can also raise blood pressure temporarily. This is different from a hypertensive crisis and usually improves once the cause is addressed.

The doctor first confirms the blood pressure reading with repeated measurements using a properly sized cuff, sometimes on both arms. The doctor then asks about your symptoms, your history of hypertension, medicines you take or have stopped, use of over-the-counter medicines and other substances, and the possibility of pregnancy. The goal is to assess whether new organ damage has already occurred, because this determines whether your condition is a hypertensive emergency.

The physical examination covers the heart, lungs, and nerve function, as well as an examination of the back of the eye (funduscopy) to look for bleeding or swelling of the optic nerve. An ECG and a troponin test assess strain on and damage to the heart muscle. Blood and urine tests assess kidney function, electrolytes, blood cells, and protein in the urine. A chest X-ray helps show fluid in the lungs and the size of the heart. If there are neurological symptoms, the doctor orders a CT scan or MRI of the head, and if an aortic tear is suspected, the doctor orders a CT angiography of the aorta.

If your blood pressure reading at home is very high, sit quietly for five minutes and then measure again. If the result is still 180/110 mmHg or higher without symptoms, contact your doctor or go to a health facility on the same day, and do not take extra medicine on your own. Go to the emergency room right away if high blood pressure comes with any of the following signs:

• Chest pain or shortness of breath
• Drooping face, slurred speech, or weakness on one side of the body
• Very severe headache with vomiting or confusion
• Sudden blurred vision or loss of vision
• Severe, tearing pain in the chest or back
• Seizures or reduced consciousness