20th June 2026

Management

Management of hypertensive emergencies should not be delayed whilst investigating end-organ damage and underlying cause. Patients are usually kept on a cardiac monitor and commenced on parenteral anti-hypertensive medication with the aim of gradual reduction in blood pressure to avoid renal, cerebral or cardiac ischaemia. This is with a few exceptions, as detailed below.

Generally, it is recommended to reduce blood pressure by no more than 25% in the first hour. A further reduction is done in the next 4-6 hours with an aim of reaching a normal blood pressure within 24-48 hours, and weaning parenteral infusion.

There are a few exceptions:

• Patients suffering from an ischaemic stroke should not have an aggressive reduction in blood pressure and may benefit from maintaining a very high blood pressure to maintain cerebral perfusion.
• On the other hand, patients with ischaemic stroke who are candidates for thrombolysis should have a gentle reduction in their blood pressure <185/110 before thrombolysis.
• Patients suffering from an aortic dissection should have aggressive reduction in blood pressure within the first hour to a systolic less than 120mmHg.
• Patients with pre-eclampsia, eclampsia or phaeochromocytoma crisis should have a reduction in their blood pressure within the first hour to a systolic <140mmHg.