Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

Investigation (All suspected cases):

Blurring of the optic nerve , diffuse peripapillary cotton‐wool spots, flame‐shaped, hemorrhages, diffuse exudates, and. a macular star.
  • ECG
  • Bloods: FBC, U&E
  • Urine: Dip (protein and blood), Microscopy, Pregnancy (if childbearing age)
  • Fundoscopy: is a critical part of the diagnostic workup – Digital Retinal Imaging is the method of choice currently


Further Investigations  (Specific Indications – not always in ED):

  • Troponin (Suspected MI)
  • BNP (Heart Failure)
  • CXR (Pulmonary Oedema)
  • CT Aorta (Suspected acute aortic disease e.g. aortic dissection)
  • CT/MRI Brain (Nervous system involvement)
  • Renal ultrasound (Renal impairment or suspected renal artery stenosis)
  • Urine drug screen (Suspected methamphetamine or cocaine use)




Hypertensive Emergency Treatment

Disease Specific IV therapies recommended by (ESC/ESH) – but liaise with local speciality teams as these patients will need admission

Clinical IndicationTarget/TimingFirst LineSecond Line
Malignant HypertensionSeveral hours
Reduce MAP by 20–25%
Labetalol/Nicardipine Nitroprusside
Hypertensive EncephalopathyImmediately
Reduce MAP by 20–25%
Labetalol/Nicardipine Nitroprusside
Acute Coronary EventImmediately
Reduce sBP <140mmHg
Acute Cardiogenic Pulmonary OedemaImmediately
Reduce sBP <140mmHg
Nitroglycerine/Nitroprusside with Fruosemide Urapidil with Furosemide
Aortic DissectionImmediately
Reduce sBP <120mmHg AND HR <60bpm
Eclampsia, Severe Pre-Eclampsia/HELLPImmediately
Reduce sBP <160mmHg AND dBP <105mmHg
Labetalol/Nicardipine with Magnesium SulphateConsider Delivery


Non-Emergent Hypertension Treatment – NICE

  • Oral therapy is normally sufficient
    • Calcium Channel Blockers are probably our 1st line in ED – as ACEi require renal monitoring
    • If already on extensive Antihypertensive therapy – Medical review will be required
    • If Adjusting/Starting oral antihypertensives there is no need for patient to wait in ED for BP to drop
  • Life style advice is also useful
  • Discharge for GP Follow-Up within 7 days


Phaeochromocytoma! (suspected cases require urgent medical review)

  • Episodic symptoms (the 5 ‘Ps’):
    • Paroxysmal hypertension,
    • Pounding headache,
    • Perspiration,
    • Palpitations
    • Pallor
  • Blood Pressure may be: Labile OR  Surges precipitated by drugs (e.g. β-blockers, metoclopramide, sympathomimetics, opioids, and tricyclic antidepressants)
  • Skin inspection: cafe-au-lait patches of neurofibromatosis


  • CT/MRI
  • Plasma or 24hr urinary fractionated metanephrines


  • First Line Blood pressure managment α- adrenergic receptor blockers
    • Don’t use β-Blockers Alone (risk of hypertension)
  • Surgical management is the ultimate treatment

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