Hypertensive Crisis

A hypertensive crisis means you suddenly have very high blood pressure. The top number (systolic blood pressure) can be 180 mm Hg or higher, and/or the bottom number (diastolic blood pressure) can be 120 mm Hg or higher. Normally, the top number should be below 120, and the bottom number should be below 80.

About 1 to 2 out of every 100 people who have high blood pressure experience a hypertensive crisis. But this can also happen to people who’ve never had blood pressure problems before.

You might hear the term “malignant hypertension.” This is a historical term from the early 20th century. It means your blood pressure is raised and causing sudden damage to organs like your kidneys or heart. Healthcare providers don’t use this term much anymore.

There are two main types of hypertensive crises:

• Severe hypertension (formerly called hypertensive urgency): You have very high blood pressure, but no signs of organ damage.
• Hypertensive emergency: You have very high blood pressure AND signs of damage to organs like your heart, eyes, brain, kidneys or aorta. Severe preeclampsia and eclampsia during pregnancy are also in this category.

Symptoms of a hypertensive crisis

Severe hypertension (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 (very high blood pressure with organ damage) include:

• Altered mental status
• Chest pain
• Dizziness
• Edema
• Heart palpitations
• Peeing less than usual
• Seizures
• Severe headache
• Symptoms and signs of stroke, like 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

What causes a hypertension crisis?

The most common cause of a hypertensive crisis is not taking your blood pressure medicines as prescribed. This might mean you don’t take them on schedule, or you suddenly stop taking them. Other causes include:

• Kidney disease
• Endocrine issues
• Anxiety or panic attack
• Consuming too much sodium
• Use of addictive substances
• Head trauma
• Brain tumor
• 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)

Your blood pressure is controlled by a complex interplay between the nervous system, the circulatory system, the kidneys and regulatory hormones. The factors above can lead to elevated blood pressure by suddenly affecting these systems in your body.

Risk factors

Your risk of a hypertensive crisis may be higher if you:

• Have obesity (BMI of 30 or higher)
• 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 damage your organs or even be fatal. Possible complications that healthcare providers check for include:

• A sudden, rapid decline in heart function
• Sudden fluid buildup in your lungs
• Sudden loss of kidney function
• A tear in your largest artery
• Bleeding around your brain
• Lack of blood flow to your heart
• Lack of blood flow to your brain or eye
• Temporary brain dysfunction

How doctors diagnose this condition

Healthcare providers diagnose severe hypertension and hypertensive emergencies at routine checkups, during hospital stays and in the emergency room. The exact process varies based on where you are.

In general, a provider will take your blood pressure in both arms. They’ll also review your medical history, talk to you about your symptoms and do a physical exam. You may need some tests to help find the cause and check for signs of organ damage.

Possible tests include:

• Blood tests
• CT scan of your chest and head
• Echocardiogram
• Electrocardiogram (EKG/ECG)
• Fundus photography
• Neurological exam
• Urine tests

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

How is a hypertensive crisis treated?

Treatment involves medications to bring your blood pressure down to a safe level. But the exact details, like whether you receive medication through an IV or take pills by mouth, depend on whether you have signs of organ damage.

If you have severe hypertension (no organ damage):

• Healthcare providers will adjust the usual blood pressure medications you take by mouth. This may involve taking a higher dose.
• They’ll tell you exactly which medications to take and when.
• You’ll likely go home the same day and see a provider for a follow-up visit in a few weeks.

If you have a hypertensive emergency (organ damage):

• Hypertensive emergency is a condition that often needs to be addressed in an intensive care unit.
• Providers will likely give you medicine directly into your veins (through an IV). They may also constantly monitor your blood pressure using an arterial line inserted into your wrist or leg.
• Your care team will decide how quickly to bring down your blood pressure. In some cases, lowering it too quickly can prevent your organs and tissues from getting enough blood. So, they may lower it gradually over 24 to 48 hours.
• You’ll need to stay in the intensive care unit (ICU) for a couple of days.
• Before you go home, you’ll receive instructions for follow-up visits.

Medications

Medicines for hypertensive emergency treatment include:

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

There’s a very large number of antihypertensive medications that healthcare providers can use for hypertensive urgency.

The medications providers use depend on the underlying medical issues associated with the elevated blood pressure. Your providers will choose the right medicine for your needs.

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 and you have any symptoms, like chest pain, headache or vision changes. You may be having a hypertensive emergency. You need medical care and treatment right away.

If your blood pressure is 180/120 mm Hg or higher and you do NOT have any symptoms, rest for several minutes. Then, take your blood pressure again. If it does not go down, seek medical care. If it goes down, call your usual healthcare provider and let them know what happened. Follow their guidance on what to do next.

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.