What is a hypertensive emergency?

When to seek immediate medical attention for elevated blood pressure

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Even with very high blood pressures of over 180 mmHg and 110 mmHg diastolic, most patients do not experience immediate signs and symptoms. However, some patients with significantly elevated blood pressure will experience damage to one or more “end-organs,” including the brain, heart, or kidney. When a patient who has a significant elevation of blood pressure experiences damage to one or more organs as a result, this may be due to a hypertensive urgency or a hypertensive emergency, and rapid treatment should be instituted.

Some signs that blood pressure elevation is causing end organ damage include neurologic symptoms, like stroke or seizures; changes in the retina that can be seen when the doctor examines the eyes with an ophthalmoscope; nausea or vomiting that might signify increased pressure in the brain; chest pain or discomfort from angina or a tear in the large blood vessel known as the aorta; or shortness of breath, which can occur from fluid buildup in the lungs.

Women who are pregnant who develop very high blood pressure or even just a significant rise from their baseline may be developing a condition known as preeclampsia or eclampsia. Eclampsia is diagnosed when a women who is nearing delivery develops high blood pressure and seizures. The only cure for eclampsia is delivery.

If you have high blood pressure, it is important to be aware of the signs of a hypertensive emergency. At these times, you should be evaluated immediately in the Emergency Department.

The doctor will perform an ECG, and will usually check a urine specimen to determine if your kidneys are functioning properly. A chest X-ray is a normal part of this work-up, and can show fluid, heart failure, or a tear in the aorta, known as an aortic dissection. If you have exhibiting confusion, seizures, or any neurologic signs, your doctor will evaluate you with a computerized tomography scan (CT) of the brain.


Although it is important to keep your blood pressure well-controlled with lifestyle modifications, salt restriction, and medication, most damage from hypertension occurs over a long period of time. Hypertensive emergencies occur vary rarely, but it’s important to identify and treat them promptly. Your doctor will carefully lower your blood pressure, but must balance the need to reduce your blood pressure against the risk of reducing critical blood flow to the heart or brain.

The most commonly diagnosed hypertensive emergency is a stroke, followed by pulmonary edema (fluid in the lungs.) If you are experiencing a stroke, and it is not hemorrhagic (resulting from a ruptured blood vessel), it will be important to preserve a high enough blood pressure to maintain the blood flow to your brain. In cases of a ruptured blood vessel in the brain, your blood pressure management will depend upon the degree of your blood pressure elevation and appropriate plan for treatment of your stroke. If you develop hypertensive encephalopathy, which results in confusion and even coma, then your doctor will aggressively lower your blood pressure by 10 to 20% in the first hour of treatment, which usually results in resolution of symptoms.

Cardiac emergencies that may occur with severe hypertension include sudden, or acute, heart failure. The heart will not be able to contract efficiently against the high blood pressure in the aorta, and fluid will collect in the lungs. This condition is known as pulmonary edema and it results in shortness of breath from fluid overload. Pulmonary edema in a hypertensive emergency is usually treated with a diuretic medication, to reduce the fluid load, although another intravenous medication to lower blood pressure may be necessary.

A hypertensive emergency can also result in damage to the kidneys. Your doctor will be able to determine if you are experiencing kidney damage by examining your blood and urine. 

If you have hypertension, then you should be alert for symptoms that may be associated with sudden severe episodes. Call 9-1-1 immediately if you have signs and symptoms of hypertensive emergency.

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