Classification and diagnosis of severely elevated blood pressure

National Heart Foundation of Australia, 2016.

Severely elevated blood pressure (BP) may be an incidental finding of a routine BP measurement (by a patient or clinician), or may be actively looked for in response to the presence of specific symptoms. Confirm that BP elevation is sustained by taking multiple measurements; see Measurement of blood pressure for information on accurate measurement of BP.

Severely elevated BP can be ranked into 3 categories—Severely elevated BP without symptoms, Hypertensive urgency and Hypertensive emergency—depending on the extent of BP elevation, as well as the presence or absence of symptoms or end-organ damage or dysfunction. These categories guide both the choice and the urgency of treatment.

The defining features and appropriate management of each category of severely elevated BP are outlined in Defining features and management of severely elevated blood pressure.

Table 1. Defining features and management of severely elevated blood pressure
[NB1] [NB2]

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Severely elevated BP without symptoms Hypertensive urgency Hypertensive emergency
Severely elevated BP without symptoms
Typical blood pressure (mmHg)	180/110 or higher
Symptoms (headache or dizziness)	not present
End-organ damage or dysfunction [NB3]	not present
Immediate threat to life	no [NB4]
Timeframe to achieve initial BP reduction	1 to 2 days [NB4]
Initial management goals	reduce BP to a safe level, usually below 180 mmHg systolic
Drug delivery route	oral
Management setting	primary care, with follow-up within days [NB4]
Hypertensive urgency
Typical blood pressure (mmHg)	180/110 or higher
Symptoms (headache or dizziness)	present
End-organ damage or dysfunction [NB3]	acute end-organ damage or dysfunction is not present moderate nonacute damage or dysfunction may be present
Immediate threat to life	no [NB4]
Timeframe to achieve initial BP reduction	hours [NB4]
Initial management goals	relieve symptoms and reduce BP to a safe level, usually below 180 mmHg systolic
Drug delivery route	oral
Management setting	usually hospital (ED), with possible admission for ongoing management
Hypertensive emergency
Typical blood pressure (mmHg)	usually 220/140 or higher [NB5]
Symptoms (headache or dizziness)	present
End-organ damage or dysfunction [NB3]	significant acute end-organ damage or dysfunction is present
Immediate threat to life	yes
Timeframe to achieve initial BP reduction	within minutes
Initial management goals	reduce BP quickly but without causing a precipitous fall in BP, which is difficult to correct avoid lowering BP by more than 25% in the first 2 hours
Drug delivery route	intravenous
Management setting	hospital (ED, ICU or CCU), with admission for ongoing management
Note: BP = blood pressure; CCU = coronary care unit; ED = emergency department; ICU = intensive care unit NB1: Information in this table does not apply to pregnant patients. For information on urgent control of elevated BP in pregnancy, see Pregnancy and severely elevated blood pressure. NB2: Evidence to guide the management of severely elevated BP is limited, so guidelines are based on current literature and expert consensus. NB3: Acute end-organ damage or dysfunction may include pulmonary oedema, kidney failure, hypertensive encephalopathy, papilloedema or cerebrovascular haemorrhage. End-organ damage is used in this guide, but other terms in the literature include hypertensive-mediated organ damage, acute hypertensive-mediated organ damage and target organ damage. NB4: The presence of any of the risk factors listed in Factors to consider in the management of severely elevated blood pressure increases the risk of complications or urgency of treatment. NB5: The defining diagnostic feature of a hypertensive emergency is acute end-organ damage or dysfunction, which can occur at lower BP levels. Defining BP thresholds vary in the literature.