Hypertensive Crisis

A hypertensive crisis means you suddenly have very high blood pressure. Normally, your blood pressure should be:

• Top number (systolic) below 120 mm Hg
• Bottom number (diastolic) below 80 mm Hg

During a hypertensive crisis, it jumps much higher:

• Top number: 180 mm Hg or higher, AND/OR
• Bottom number: 120 mm Hg or higher

A hypertensive crisis is a medical emergency. Go to the emergency room (ER) for treatment.

Most people who have a hypertensive crisis have high blood pressure (hypertension). This means their blood pressure is higher than it should be from day to day. Experts estimate that about 1% to 2% of people with high blood pressure experience a hypertensive crisis. But such crises can also affect people who’ve never had blood pressure problems before.

Types of this condition

There are two main types of hypertensive crises:

• Hypertensive urgency. You have very high blood pressure, but no signs of organ damage. Some healthcare providers call this “uncontrolled hypertension” instead of hypertensive urgency. No matter the term used, the goal is to get your numbers to a healthy range.
• Hypertensive emergency. You have very high blood pressure that’s causing new or worsening organ damage. Examples of affected organs include your heart, aorta, eyes, brain and kidneys. Severe preeclampsia and eclampsia are also considered hypertensive emergencies in pregnant patients.

You might also hear your provider use the term “malignant hypertension.” This is a historical term from the early twentieth century. It describes sudden damage to your kidneys and eyes from extremely high blood pressure. Out of habit, some providers still use this term when talking about hypertensive emergency. But providers generally prefer the term “hypertensive emergency” because it has a more specific definition today.

Symptoms of a hypertensive crisis

Hypertensive crisis symptoms depend on whether or not there’s organ damage.

Hypertensive urgency (very high blood pressure without organ damage) usually doesn’t have symptoms. The only way you know your blood pressure is very high is by checking it. But it’s also possible to have symptoms like:

• Anxiety
• Mild headache
• Nosebleed
• Shortness of breath

Symptoms of a hypertensive emergency (high blood pressure with organ damage) include:

• Altered mental status
• Chest pain
• Dizziness
• Edema (swelling)
• Heart palpitations
• Peeing less than usual
• Seizures
• Severe headache
• Symptoms and signs of stroke, such as sudden facial droop, slurred speech or sudden weakness in your arms and/or legs
• Vision changes, including eye pain, loss of vision or sudden blurry vision

During an exam, your provider may notice these signs of a hypertensive emergency:

• Bulging neck veins (jugular venous distention)
• Crackling sounds in your lungs
• Heart murmurs that you didn’t have before
• Blood vessel damage in the back of your eye
• Unusual asymmetric weakness that raises suspicion for a stroke

What causes a hypertension crisis?

Hypertensive crisis causes include:

• Not taking your blood pressure medicines as prescribed, for any reason (most common cause)
• Suddenly stopping the use of your blood pressure medicines
• Medicines interacting with each other
• Kidney disease
• Endocrine issues
• Preeclampsia or eclampsia during pregnancy
• Use of certain addictive substances
• Head trauma
• Brain tumor
• Certain medicines you take for other conditions

Medicines that may cause a hypertensive crisis include:

• Steroids
• Medicines for depression
• Cyclosporine
• Pseudoephedrine (an ingredient in some cold and flu products)

Risk factors

You may have a higher risk of having a hypertensive crisis if you:

• Have obesity
• Are male
• Are Black
• Don’t take your blood pressure medicines consistently
• Use stimulant drugs that aren’t prescribed for you

Complications of a hypertensive crisis

Dangerously high blood pressure can lead to:

• A sudden, rapid decline in heart function (acute heart failure)
• Sudden fluid buildup in your lungs (acute pulmonary edema)
• Sudden loss of kidney function (acute kidney failure)
• A tear in your largest artery (aortic dissection)
• Bleeding around your brain (intracranial hemorrhage)
• Lack of blood flow to your heart (heart attack)
• Lack of blood flow to your brain (ischemic stroke)
• Temporary brain dysfunction (hypertensive encephalopathy)

How doctors diagnose this condition

A healthcare provider will take your blood pressure in both arms to diagnose a hypertensive crisis. They’ll also review your medical history, talk to you about any symptoms you have and do a physical exam. You may need some tests to help your provider find the cause.

Possible tests include:

• Blood tests
• Urine tests
• Electrocardiogram (EKG/ECG)
• Fundoscopic exam
• Neurological exam
• Transthoracic echocardiogram
• Computed tomography (CT) scan of your chest and head

Your provider will diagnose you with a hypertensive emergency if you have signs of new or worsening organ damage. They’ll diagnose you with hypertensive urgency if these signs aren’t there.

How is a hypertensive crisis treated?

Treatment for a hypertensive crisis happens in the emergency room. Healthcare providers give you medicine to bring your blood pressure down to a safe level.

You may go home the same day (with medicines to take on your own) if you don’t have signs of organ damage. But if you’re having a hypertensive emergency, you’ll need to stay in the intensive care unit (ICU) for a couple of days. Providers will give you medicine directly into your veins (through an IV). They’ll also continuously monitor your blood pressure.

Your care team will decide how quickly to bring down your blood pressure based on what other medical conditions you have. In some cases, lowering your blood pressure too quickly can prevent your organs and tissues from getting enough blood. So, your providers may lower it gradually over 24 to 48 hours.

But they’ll bring down your blood pressure more quickly during a hypertensive crisis if you have certain conditions like aortic dissection, severe preeclampsia or eclampsia. In these cases, the benefits of rapid lowering outweigh any risks.

Medications

Medicines for hypertensive crisis treatment include:

• Captopril
• Clevidipine
• Clonidine
• Esmolol
• Hydralazine
• Labetalol
• Nicardipine
• Nifedipine
• Nitroglycerin
• Nitroprusside

Providers choose the right medicine for your needs. They take into account your medical conditions and other medicines you’re taking.

When should I see my healthcare provider?

Call 911 or your local emergency services number if your blood pressure is 180/120 mm Hg or higher. You need treatment right away.

After receiving treatment for a hypertensive crisis, follow up with your usual healthcare provider. They may want to adjust your blood pressure medicines. They’ll also talk to you about any changes you should make in your daily life.

For example, they may recommend changing what you eat (like following the DASH diet) or adding more physical activity to your routine.

What can I expect if I have this condition?

A hypertensive crisis is a warning sign that your blood pressure isn’t where it needs to be. Your provider will help you lower your blood pressure and keep it at healthy levels. Make sure to keep all your follow-up appointments and take your medicines exactly as your provider prescribes them.