Management of Severe Hypertension in Adults

Severely elevated blood pressure can cause both patients and providers to become alarmed. But aggressive treatment may cause more harm than good (e.g., renal, myocardial, or cerebral ischemia).1 The FAQ below addresses the general management of adult, nonpregnant patients presenting with severely elevated blood pressure, with a focus on pharmacotherapy. Our chart, Drug Options for Hypertensive Emergency, provides suggested dosing and other pertinent information for parenteral antihypertensive agents. For information on severe hypertension in pregnancy, see our FAQ, Hypertension in Women: Before, During, and After Pregnancy.


Answer/Pertinent Information

How are patients who present with severe hypertension classified?

  • Hypertensive emergency: BP >180/120 mmHg with target organ damage (new or worsening).1 Examples include encephalopathy, intracerebral hemorrhage, ischemic stroke, unstable angina, myocardial infarction, left ventricular failure with pulmonary edema, aortic aneurysm dissection, and acute renal failure.1,4 Patients might report chest pain; shortness of breath; swelling; mental status changes; or speech, vision, or gait changes.2,3 Note that patients without target organ damage might still have symptoms (e.g., headache, atypical chest pain, dyspnea, dizziness, lightheadedness, nosebleed).2
  • Hypertensive urgency(some experts prefer “asymptomatic uncontrolled hypertension”6or “severe asymptomatic hypertension”7): severe blood pressure elevation in a patient who is stable, without actual or impeding impact on target organs.1 Some experts would handle patients with known aortic or intracranial aneurysms akin to those with emergencies.7
  • Note that a blood pressure threshold of >180/120 mmHg is somewhat arbitrary; also consider baseline blood pressure and rate of increase.1

In what settings can severe hypertension be treated?

  • Hypertensive emergency: intensive care setting for continuous BP monitoring and administration of a parenteral antihypertensive1
  • Hypertensive urgency: does not require emergency department or hospital management1

What are the BP goals for treatment of severe hypertension?

Hypertensive emergency:

  • Aortic dissection: reduce SBP to ≤120 mmHg within the first 20 to 60 min1
  • Pheochromocytoma: reduce SBP to <140 mmHg within an hour1
  • Acute ischemic stroke: see our resource, Acute Ischemic Stroke Pharmacotherapy Checklist
  • Intracerebral hemorrhage: reduce SBP to <220 mmHg [Evidence level C].1 Immediate reduction to <140 mmHg doesn’t help, and may be harmful [Evidence level A-1].8
  • For other patients, SBP should be reduced by ≤25% within the first hour, then reduce BP to 160/100 mmHg within the next two to six hours if stable. Then reduce to the normal range in the next 24 to 48 hours.1

Hypertensive urgency: begin/restart/adjust treatment and follow-up in a matter of days.1,2 Work toward individualized blood pressure goal with at least monthly follow-up.3

What are the treatment options for hypertensive emergencies?

  • Due to impaired tissue perfusion, the preferred treatment is continuous infusion of a short-acting, titratable antihypertensive to limit target organ damage.1
  • No particular agent has been shown in RCT to improve morbidity or mortality.1
  • For Drugs and Adult Doses, see table below. For options in acute ischemic stroke, see our resource, Acute Ischemic Stroke Pharmacotherapy Checklist.
  • Consider starting an oral agent six to 12 hours after starting parenteral therapy.2

What are the treatment options for hypertensive urgencies?

  • Ask about medication adherence, diet (e.g., salt intake), new medications (e.g., NSAIDs), pain, and usual blood pressure.3,6
  • After confirming elevation after 20 to 30 minutes of rest, restart or step-up antihypertensive therapy.1,2 Thirty minutes of rest reduces blood pressure to <180/110 mmHg in a third of patients.2
  • Treat anxiety, if applicable.1
  • Avoid use of oral antihypertensive loading doses, immediate-release nifedipine, or intravenous medications due to risk of hypotension.1,2 In hypertensive urgencies, failure to aggressively reduce blood pressure does not increase risk short-term. In the week after presentation, only 1 in 1,000 patients has a cardiovascular event [Evidence level B-3].9
  • Arrange follow-up within seven days, with phone follow-up in the meantime.2,7 Consider earlier follow-up for patients with cardiovascular or renal disease.Patients should be followed at least monthly until blood pressure goal is reached.3

What are some patient counseling points pertaining to severe hypertension?

  • Ensure patients are taking their blood pressure correctly to avoid “false alarms” (e.g., advise sitting quietly for five minutes before checking BP, using the correct cuff size, etc).
  • Promote antihypertensive adherence to prevent recurrence.

Abbreviations: ACC = American College of Cardiology; AHA = American Heart Association; BP = blood pressure; IV = intravenous; MAOI = monoamine oxidase inhibitors; RCT = randomized controlled trial

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.



Study Quality


Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study


Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study


Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.]


  1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018;71:e13-115.
  2. Peixoto AJ. Acute severe hypertension. N Engl J Med 2019;381:1843-52.
  3. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018;39:3021-104.
  4. Hypertension Canada. Supplemental Table S2. Examples of hypertensive urgencies or emergencies. (Accessed June 28, 2021).
  5. Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med 2003;41:513-29.
  6. van den Born BH, Lip GYH, Brguljan-Hitij J, et al. ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmaother 2019;5:37-46.
  7. Varon J, Elliott WJ. Management of severe asymptomatic hypertension (hypertensive urgencies) in adults. (Last updated February 13, 2019). In UpToDate, Post TW (ed), UpToDate, Waltham, MA 02013.
  8. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016;375:1033-43.
  9. Patel KK, Young L, Howell EH, et al. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting. JAMA Intern Med 2016;176:981-8.

Cite this document as follows: Clinical Resource, Management of Severe Hypertension in Adults. Hospital Pharmacist’s Letter/Pharmacy Technician’s Letter. July 2021. [370719]

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