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Hypertensive Emergency Management (ESC 2024)

Hypertensive Emergency Management (ESC 2024): Severe BP: ≥180/110 mmHg → Pregnant or postpartum? → Pregnant or postpartum: treat BP ≥160/110 mmHg now → ...

Pathway Overview

19 steps

Algorithm Steps

19 total

  1. 01Start

    Severe BP: ≥180/110 mmHg

    Adults. Pregnant or postpartum: act at ≥160/110 mmHg.

    • Repeat the measurement to confirm
    • Relieve pain, distress or urinary retention; BP may settle
    • Ask about cocaine, amphetamines, and missed or stopped BP drugs
  2. 02Decision

    Pregnant or postpartum?

    Severe hypertension in pregnancy starts at 160/110 mmHg

  3. If Yes
    1. 03Warning

      Pregnant or postpartum: treat BP ≥160/110 mmHg now

      Target <160/110 mmHg. Call obstetrics. Asthma: no labetalol. Magnesium sulfate for eclampsia, or pre-eclampsia with severe hypertension or neurological signs.

      • IV labetalol (not in asthma), IV hydralazine or oral immediate-release nifedipine
      • In pregnancy: no ACE inhibitor or ARB; nitroprusside only as a last resort
      • Pre-eclampsia with pulmonary oedema: IV GTN infusion
    2. 04Outcome

      Obstetric and critical care

      Monitor mother and fetus. Plan timing of birth with obstetrics. BP not controlled on 2 drugs: ICU review. Stroke, ICH, aortic dissection or ACS: also use that emergency's BP target with the specialist team. Doses: SOMANZ 2023 Flowchart 6.2 or local obstetric protocol.

    If No
    1. 05Decision

      Acute organ damage?

      Brain, heart, aorta, kidney or retina. Tests: ECG, creatinine, electrolytes, FBC, LDH, urinalysis, fundoscopy.

      • Brain: encephalopathy (confusion, seizures, cortical blindness), stroke, ICH
      • Heart and aorta: ACS, acute pulmonary oedema, aortic dissection
      • Retina: flame haemorrhages, cotton-wool spots, papilloedema
      • Kidney and blood: AKI; haemolysis with low platelets (TMA)
      • Sudden severe BP from phaeochromocytoma
      • As indicated: troponin, blood film, chest X-ray, echo, CT brain or CT aorta
    2. If Yes
      1. 06Warning

        Hypertensive emergency: IV therapy in a monitored bed

        ICU, HDU or resus bay with continuous BP monitoring. Ischaemic stroke without reperfusion: do not lower BP unless >220/120 mmHg.

        • Do not lower BP rapidly or without control
        • Target and speed depend on the organ affected
        • Find the trigger: stimulants, drug withdrawal, phaeochromocytoma
      2. 07Warning

        No beta-blocker in pulmonary oedema, HF, bradycardia, AV block or asthma

        Applies to labetalol and esmolol. AV block means 2nd- or 3rd-degree block.

        • Cocaine or amphetamine toxicity: benzodiazepines first; no beta-blocker
        • Phaeochromocytoma: alpha-blockade before any beta-blocker
        • GTN: not with RV infarction, severe aortic stenosis, or a PDE-5 inhibitor in the last 24–48 h
      3. 08Action

        IV agents available in Australia

        Short-acting and titratable. Doses: local protocol or Australian product information.

        • Labetalol IV (beta-blocker): first line for most emergencies
        • GTN IV infusion: ACS and acute pulmonary oedema
        • Sodium nitroprusside IV infusion: cyanide risk; caution in liver or kidney failure
        • Esmolol IV (beta-blocker): aortic dissection
        • Clevidipine IV: not with soy or egg allergy, or severe aortic stenosis
        • Nicardipine, urapidil and phentolamine are not on the ARTG
      4. 09Decision

        Which emergency?

        Go to the matching step. Targets and drugs differ by organ.

      5. Malignant HT / encephalopathy / AKI
      6. 10Action

        Malignant hypertension, encephalopathy, AKI or TMA: lower MAP 20–25%

        Encephalopathy: start at once. Malignant hypertension: over several hours.

        • Do not drop MAP by more than 50%: risk of stroke and death
        • IV labetalol first line; nitroprusside alternative
        • Then, if stable, lower BP gradually over 24–48 h
        • Encephalopathy with focal signs: image the brain for stroke
      7. 11Outcome

        Monitored care until BP is stable

        Then switch to oral therapy. Screen for secondary hypertension; these patients stay at high risk.

      8. Ischaemic stroke
      9. 12Action

        Ischaemic stroke: lower BP only for reperfusion or BP >220/120 mmHg

        Otherwise do not actively lower BP. Involve the stroke team.

        • Thrombolysis: <185/110 mmHg before; <180/105 mmHg for 24 h after
        • Thrombectomy: <180/105 mmHg before and for 24 h after
        • After successful thrombectomy: do not target SBP <140 mmHg
        • No reperfusion and BP >220/120 mmHg: lower by about 15% over 24 h
        • IV labetalol first line
      10. Path rejoins step 11Shared downstream outcome
      11. ICH
      12. 13Action

        Intracerebral haemorrhage: SBP 140–160 mmHg within 6 h

        Do not go well below 140 mmHg. Involve the stroke team.

        • SBP ≥220 mmHg: do not drop SBP by more than 70 mmHg in the first hour
        • IV labetalol first line
        • On an anticoagulant: follow the ICH reversal protocol
      13. Path rejoins step 11Shared downstream outcome
      14. ACS
      15. 14Action

        Acute coronary syndrome: SBP <140 mmHg within 1 h

        IV GTN first line. Labetalol if no beta-blocker contraindication.

        • Cocaine or amphetamine: benzodiazepines and GTN; no beta-blocker
        • Follow the ACS pathway for reperfusion and antithrombotic therapy
      16. Path rejoins step 11Shared downstream outcome
      17. Pulmonary oedema
      18. 15Action

        Acute pulmonary oedema: SBP <140 mmHg within 1 h

        IV GTN or nitroprusside, with an IV loop diuretic. No beta-blocker.

        • CPAP or NIV can help
        • Follow the acute heart failure pathway
      19. Path rejoins step 11Shared downstream outcome
      20. Aortic dissection
      21. 16Action

        Aortic dissection: SBP <120 mmHg and HR <60/min within 1 h

        Rate control first: IV esmolol or labetalol. Beta-blocker contraindicated: IV verapamil (not in heart failure or AV block). No vasodilator before rate control. Call cardiothoracic surgery.

        • Hypotension or shock: do not lower BP; suspect tamponade or rupture
        • Vasodilator after rate control: nitroprusside, GTN or clevidipine
        • Acute severe aortic regurgitation: caution with beta-blockers
        • Urgent CT aortogram
        • Type A: emergency surgery
      22. Path rejoins step 11Shared downstream outcome
      23. Phaeo / stimulants
      24. 17Warning

        Phaeochromocytoma or stimulant toxicity: no beta-blocker first

        Cocaine or amphetamine: benzodiazepines first. Phaeochromocytoma: alpha-blockade first.

        • Then IV phentolamine (not on the ARTG) or nitroprusside
        • Labetalol has made BP worse in phaeochromocytoma
        • Stimulant chest pain: add GTN and aspirin
      25. Path rejoins step 11Shared downstream outcome
      If No
      1. 18Action

        No acute organ damage: severe hypertension, not an emergency

        Lower BP gradually with oral therapy. Do not lower BP rapidly.

        • No IV agents; no immediate-release nifedipine
        • Cocaine or amphetamine: benzodiazepines and observe; no beta-blocker
        • Start or intensify oral therapy (ESC 2024 Section 8)
        • Check adherence and look for secondary causes
        • Arrange early outpatient BP review
      2. 19Outcome

        Discharge on oral therapy with early review

        Admission is usually not needed.

Guideline Source

2024 ESC Guidelines for Elevated Blood Pressure and Hypertension

DOI: 10.1093/eurheartj/ehae178View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Not for children.
  • No drug doses: use the local protocol or Australian product information.
  • Stroke and ICH targets: follow the local stroke protocol.

Contraindicated Populations

pediatric

Applicable Regions

EUUSAU

AU: Pregnancy: SOMANZ 2023. Stroke: Stroke Foundation living guideline. Nicardipine, urapidil and phentolamine are not on the ARTG.

EU: ESC 2024 hypertension guideline, Section 10

US: 2025 AHA/ACC high BP guideline: about 25% reduction in the first hour, then gradual further reduction over 24-48 h

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Hypertensive Emergency Management (ESC 2024)?

The Hypertensive Emergency Management (ESC 2024) is a emergency clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2024 ESC Guidelines for Elevated Blood Pressure and Hypertension.

What guideline is the Hypertensive Emergency Management (ESC 2024) based on?

This algorithm is based on 2024 ESC Guidelines for Elevated Blood Pressure and Hypertension (DOI: 10.1093/eurheartj/ehae178).

What are the limitations of the Hypertensive Emergency Management (ESC 2024)?

Known limitations include: Adults only. Not for children.; No drug doses: use the local protocol or Australian product information.; Stroke and ICH targets: follow the local stroke protocol.. Individual patient factors may require deviation from these recommendations.

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