Hypertensive emergency: Difference between revisions
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''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''
==Background==
*''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''
 
 
*Definition: acute target-organ damage due to severely elevated blood pressure
**Blood pressure is generally ≥180/110-120, but presence of end-organ damage defines disease (not absolute blood pressure number)
**1%-6% of all ED patients will present with severe hypertension, but less than half of those will have target organ damage<ref>Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252. doi:10.1161/01.HYP.0000107251.49515.c2</ref>
**From 2006-2013, hypertensive emergencies occurred in approximately 2 per 1000 adult ED visits<ref name="AHA2024">Bress AP, Anderson TS, Flack JM, et al. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension. 2024;81(8):e94-e106. doi:10.1161/HYP.0000000000000238</ref>


==Background==
===Updated Terminology (AHA 2024)===
*Definition: end-organ damage due to hypertension
''The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"''<ref name="AHA2024"/>
**Blood pressure is generally >180/120 (usually > 220/130), but presence of end-organ damage defines disease (not absolute blood pressure number)
*'''Hypertensive emergency''': SBP ≥180 or DBP ≥110-120 mmHg '''with''' new or worsening target-organ damage
*Asymptomatic markedly elevated BP: SBP ≥180 or DBP ≥110-120 mmHg without target-organ damage (replaces "hypertensive urgency")
*Asymptomatic elevated BP: SBP >130 or DBP >80 mmHg without target-organ damage


===Etiology===
===Etiology===
*Idiopathic
*Idiopathic (medication nonadherence most common)
*[[Sympathomimetic]] drug use
*[[Sympathomimetic]] drug use
*[[Preeclampsia]]
*[[Preeclampsia]]
*Acute [[glomerulonephritis]]
*Acute [[glomerulonephritis]]
*[[Pheochromocytoma]]
*Renal artery stenosis
*MAOI interactions


===Prehospital===
===Prehospital===
*Prehospital BP measurements should be considered reliable<ref>Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.</ref>
*Prehospital BP measurements should be considered reliable<ref>Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.</ref>
*Acute lowering of BP is not typically recommended
*Acute lowering of BP is not typically recommended in the prehospital setting
*Focus on ABCs (assess need for [[intubation]] or [[BiPAP|respiratory support]])
*Focus on ABCs (assess need for [[intubation]] or [[BiPAP|respiratory support]])
*Provide care of treatable etiologies
*Provide care of treatable etiologies
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==Clinical Features==
==Clinical Features==
'''End-Organ Dysfunction<ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>'''
===End-Organ Dysfunction (BARKH Mnemonic)<ref name="AHA2024"/><ref>Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.</ref>===
*Acute kidney injury
Use the BARKH mnemonic to systematically evaluate for target-organ damage:
**Often with microscopic hematuria
*Brain
*Pulmonary edema
**[[Hypertensive encephalopathy]] (visual disturbances, [[seizure]], delirium)
*Type-II myocardial infarction
**[[Intracranial hemorrhage]]
*Hypertensive encephalopathy
**Acute [[Stroke (Main)|ischemic stroke]]
**Visual disturbances
*Arteries
**Seizure
**[[Aortic dissection]]
**Delirium
*Retina
**High-grade [[hypertensive retinopathy]] (hemorrhages, exudates, papilledema)
*Kidney
**[[Acute kidney injury]] (often with microscopic hematuria)
**[[Microangiopathic hemolytic anemia]] (MAHA) / thrombotic microangiopathy<ref>Cremer A, Amraoui F, Lip GY, et al. From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency. J Hum Hypertens. 2016;30(8):463-466. doi:10.1038/jhh.2015.82</ref>
*Heart
**Type-II [[myocardial infarction]] / unstable angina
**Acute LV failure with [[pulmonary edema]]


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===BP Measurement===
*Ensure proper cuff size and technique before initiating treatment
*Confirm with repeat measurement in both arms; patient should be seated, back supported, feet on floor
*For patients receiving IV antihypertensives, arterial line monitoring is preferred for accuracy<ref name="AHA2024"/>
===Workup===
===Workup===
''Consider any of the following based on the patient's clinical presentation''<ref>2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013;31(10):1925-1938.</ref>
''Consider any of the following based on the patient's clinical presentation''<ref>2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013;31(10):1925-1938.</ref><ref name="AHA2024"/>
*CBC with peripheral smear- assess for microangiopathic hemolytic anemia
*CBC with peripheral smear — assess for microangiopathic hemolytic anemia (schistocytes)
*Chem 8 - assess renal failure and possible secondary causes
*Chem 8 — assess renal failure and possible secondary causes
*LDH, haptoglobin — if MAHA suspected
*[[Troponin|Cardiac enzymes]]
*[[Troponin|Cardiac enzymes]]
*[[Urinalysis]] - Assess renal failure, glomerulonephritis, preeclampsia
*[[Urinalysis]] — assess renal failure, glomerulonephritis, preeclampsia
*[[CXR]] - evaluate for pulmonary edema or dissection
*[[ECG]] — [[LVH]], [[myocardial ischemia|ischemia]]
*[[ECG]] - [[LVH]], [[myocardial ischemia|ischemia]]
*[[Ultrasound]] — evaluate for aortic dissection, bladder outlet obstruction, or depressed myocardial function
*[[CT head]] - in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology
*[[Fundoscopic Exam]] — evaluate for hypertensive retinopathy or papilledema
**Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to [[posterior reversible encephalopathy syndrome]] (now called reversible posterior leukoencephalopathy). Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department.
*[[CXR]] — evaluate for pulmonary edema or widened mediastinum (dissection)
*[[CT head]] — in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology
**Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to [[posterior reversible encephalopathy syndrome]]. Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department.


===Diagnosis===
===Diagnosis===
*Must have evidence of end-organ dysfunction
*Must have evidence of end-organ dysfunction
**''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''
**''High blood pressure without symptoms is NOT hypertensive emergency (see [[asymptomatic hypertension]])''
**''Symptoms such as headache,epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction''
**''Symptoms such as headache, epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction''


==Management==
==Management==
*Goal: Lower mean arterial or systolic pressure by no more than 10-20% in the first hour<ref>Elliott WJ. Clinical features in the management of selected hypertensive emergencies. Prog Cardiovasc Dis. 2006;48(5):316-325. doi:10.1016/j.pcad.2006.02.004</ref>
'''High blood pressure without end organ damage is NOT hypertensive emergency (see [[asymptomatic hypertension]])'''
**Then lower by an additional 5-15% over the next 23 hours for no more than 25% in the first 24 hours
*Goal: Lower MAP by 20-25% in the first hour<ref name="AHA2025">2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Hypertension. 2025;82(10):e212-e316. doi:10.1161/HYP.0000000000000249</ref><ref>Elliott WJ. Clinical features in the management of selected hypertensive emergencies. Prog Cardiovasc Dis. 2006;48(5):316-325. doi:10.1016/j.pcad.2006.02.004</ref>
**Exception is [[aortic dissection]] which requires rapid reduction to systolic BP <110mmHg
**Then lower gradually to 160/100 mmHg over the next 2-6 hours
**Then cautiously to normal over the next 24-48 hours
**Exception is [[aortic dissection]] which requires rapid reduction of systolic BP to 100-120 mmHg
*Be careful of lowering BP in patients with [[CVA]]
*Be careful of lowering BP in patients with [[CVA]]
*Do NOT use IV antihypertensives for asymptomatic elevated BP, even if markedly elevated<ref name="AHA2024"/>


===By Drug===
===By Drug===
====First-Line Agents====
{| class="wikitable"
{| class="wikitable"
|-
|-
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| '''Notes'''
| '''Notes'''
|-
|-
| [[Nitroprusside]]
| [[Nicardipine]]
|
Start 5 mg/hr IV
 
Increase by 2.5 mg/hr q5-15min
 
Max 15 mg/hr
 
| Dihydropyridine CCB; decreases PVR
|  
|  
1. Effective for most hypertensive emergencies
2. Good for intracranial pathology
3. Does not increase ICP
4. Achieves target BP in >90% within 30 min (CLUE trial)<ref name="CLUE">Peacock WF, Varon J, Baumann BM, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care. 2011;15(3):R157. doi:10.1186/cc10289</ref>


0.3-0.5 mcg/kg/min IV initial infusion
|
1. Onset 5-15 min (slower than clevidipine)


Increase by 0.5 mcg/kg/min up to 2mcg/kg/min
2. Duration ~30-60 min; can accumulate


3. Reflex tachycardia possible


| Arterial > venodilator
|  
|  
1. Very effective
1. Avoid in decompensated CHF, severe aortic stenosis
 
2. Often considered first-line for most hypertensive emergencies


2. Immediate onset/offset
3. In CLUE subgroup with EOD, 3.65× odds of reaching target vs labetalol<ref>Levy PD, Mahn JJ, Miller J, et al. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ Open. 2013;3(3):e002338. doi:10.1136/bmjopen-2012-002338</ref>


|-
| [[Clevidipine]]
|  
|  
1. Cyanide Toxicity
Start 1-2 mg/hr IV


2. Coronary steal?
Double q2 min until approaching target


3. Increased HR
Then titrate by smaller increments q5-10 min


Max 32 mg/hr
| Dihydropyridine CCB; arterial vasodilator
|  
|  
1. Avoid in liver/renal failure
1. Ultra-short half-life (~1 min); truly titratable


2. Avoid with increased ICP
2. Organ-independent metabolism (ester hydrolysis in blood; safe in hepatic/renal failure)


3. Avoid in pregnancy
3. Rapid onset (~2-3 min)
 
4. Lower risk of overshoot hypotension vs nicardipine


|-
| [[Nitroglycerin]]
| Start 5-100 mcg/min
| Veno>arteriodilation
|  
|  
1. Rapid on/offset
1. Lipid emulsion vehicle (monitor triglycerides if >24hr)


2. Increases coronary flow
2. Higher cost than nicardipine
 
3. Risk of rebound HTN after discontinuation


| Causes tachycardia
|  
|  
Drug of choice in patients with cardiac ischemia,
1. Avoid in soy/egg allergy, severe aortic stenosis
 
2. Effective in stroke, perioperative HTN<ref>Brehaut SS, Roche AM. Emergency department and critical care use of clevidipine for treatment of hypertension in patients with acute stroke. Crit Pathw Cardiol. 2025;24(1):e0375. doi:10.1097/HPC.0000000000000375</ref>


LV dysfunction, or pulmonary edema
3. Similar initial BP control to nicardipine; nicardipine may have more sustained control<ref>Storey C, Pouliot J. Evaluation of the efficacy and safety of nicardipine versus clevidipine for blood pressure control in hypertensive crisis. J Emerg Med. 2024;67(3):e267-e275.</ref>


|-
|-
| [[Labetalol]]
| [[Labetalol]]
|  
|  
20-80mg IV bolus q10 min '''OR'''
20 mg IV bolus initially
 
Then 20-80 mg IV bolus q10 min '''OR'''


0.5-2 mg/min IV infusion or
0.5-2 mg/min IV infusion


200mg to 400mg PO BID
Max cumulative bolus dose 300 mg


| Beta>α-blocker
| Beta > α-blocker
|  
|  
1. No change in HR, cerebral flow
1. No significant change in HR or cerebral blood flow
2. Rapid onset
 
2. Rapid onset (5-10 min)
 
3. Safe in pregnancy


|  
|  
Avoid in COPD, CHF and heart block
1. Avoid in COPD, decompensated CHF, 2nd/3rd degree heart block, severe bradycardia
 
2. Less effective at reaching target BP than nicardipine in CLUE trial (82.5% vs 91.7%)<ref name="CLUE"/>


|  
|  
1. Consider in ACS
1. Consider in ACS (when beta-blockade appropriate)
 
2. Consider in ischemic CVA
2. Consider in ischemic CVA


3. First-line in aortic dissection (provides rate and BP control)
|}
====Second-Line / Specific-Use Agents====
{| class="wikitable"
|-
| '''Drug'''
| '''Dose'''
| '''Mechanism'''
| '''Pros'''
| '''Cons'''
| '''Notes'''
|-
|-
| [[Esmolol]]
| [[Esmolol]]
|  
|  
Load 250-500 mcg/kg over 2min
Load 250-500 mcg/kg over 1 min


Infuse 50 mcg/kg/min over 4min
Infuse 50 mcg/kg/min


- if ineffective repeat load, increase infusion rate by &nbsp;50mcg/kg/min up to 300mcg/kg/min
If ineffective, repeat load and increase infusion by 50 mcg/kg/min up to 300 mcg/kg/min


| Beta selective
| Beta-1 selective
| Rapid on/offset
|  
|  
Avoid in COPD, CHF
1. Very rapid on/offset (half-life 9 min)


bradycardia
2. Easily titratable


|  
|  
Consider in ACS
1. Avoid in COPD, decompensated CHF, severe bradycardia
 
2. Does not significantly lower BP alone in severe HTN
 
|
1. First-line for rate control in aortic dissection
 
2. Consider in ACS
 
3. Often used WITH a vasodilator (nicardipine/clevidipine)


|-
|-
| [[Nicardipine]]
| [[Nitroglycerin]]
| Start 5 mcg/min IV; titrate up to 200 mcg/min
| Venodilator > arteriodilator
|
1. Rapid onset/offset
 
2. Increases coronary blood flow
 
3. Reduces preload (ideal for pulmonary edema)
 
|
1. Reflex tachycardia
 
2. Headache common
 
3. Tachyphylaxis with prolonged use
 
|
Drug of choice in patients with cardiac ischemia, LV dysfunction, or pulmonary edema
 
|-
| [[Nitroprusside]]
|
0.3-0.5 mcg/kg/min IV initial
 
Max 2 mcg/kg/min (some refs up to 10)
 
| Arterial > venodilator
|
1. Very effective
 
2. Immediate onset/offset
 
|
1. Cyanide toxicity (especially with renal/hepatic failure or prolonged use)
 
2. Coronary steal
 
3. Increased ICP
 
4. Requires light-protected tubing
 
|  
|  
Start 5mg/h
'''Generally considered second- or third-line; safer alternatives preferred (nicardipine, clevidipine)'''


If ineffective after 15min increased in 2.5mg/hr interval up to 15mg/hr
Avoid in liver/renal failure, increased ICP, pregnancy


| Decreases PVR<br/><br/>
| Good for intracranial pathology
| Slower onset/offset
| Avoid in CHF, ACS
|-
|-
| [[Phentolamine]]
| [[Phentolamine]]
|  
|  
5-15mg IV bolus q5-15min '''OR'''
5-15 mg IV bolus q5-15 min '''OR'''


0.2-0.5mg/min IV infusion
0.2-0.5 mg/min IV infusion


| α-blocker
| α-blocker
| Rapid onset
| Reflex tachycardia
|  
|  
Used for catecholamine-induced hypertension (pheochromocytoma, sympathomimetic toxicity)
|-
| [[Fenoldopam]]
|  
|  
| Used for catecholamine-induced hypertension
0.1-0.3 mcg/kg/min IV
|-
 
| [[Enalaprilat]]
Titrate q15 min
| Bolus 1.25mg over 5min q6hr, titrate at 30min intervals to max of 5mg q6hr
 
| Decreases HR, SV, systemic arterial pressure
Max 1.6 mcg/kg/min
| Does not impair cerebral flow
 
| Variable response
| Dopamine-1 agonist
|  
|  
1. Used in patients at risk for cerebral hypotension, CHF
1. Increases renal blood flow and natriuresis


2. Avoid in pregnancy
2. No toxic metabolites


|-
| [[Clonidine]]
|  
|  
0.1 - 0.3 mg PO q12 scheduled; For hypertensive emergency, 0.2 mg x1, then 0.1 mg q1 hr PRN, max 0.6 mg total
1. Reflex tachycardia
 
2. Avoid in glaucoma (increases IOP)


| α-2 agonist, BP effects within 30-60 min after PO dose
|  
|  
Consider in hypertensive emergency with AKI/renal failure<ref>Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.</ref>
|-
| [[Enalaprilat]]
| Bolus 1.25 mg IV over 5 min q6hr, titrate at 30 min intervals to max of 5 mg q6hr
| ACE inhibitor; decreases HR, SV, systemic arterial pressure
| Does not impair cerebral blood flow
| Variable and unpredictable response
|  
|  
| Reduced CNS sympathetic flow, decreasing SVR, HR, BP; no renal blood flow changes; tolerance/tachyphylaxis develop quickly
1. Consider in high-renin states, CHF
 
2. '''Avoid in pregnancy'''


3. Limited role in ED


|-
|-
| [[Hydralazine]]
| [[Hydralazine]]
|  
|  
10 - 20 mg slow IV/IM bolus q4-6 hr PRN, max 40 mg/dose
10-20 mg slow IV/IM q4-6 hr PRN
 
Max 40 mg/dose


| Peripheral vasodilator, with fall in BP beginning within 30 min, lasting 2-4 hrs
| Direct arterial vasodilator; onset 10-30 min, duration 2-4 hrs
| Extensive safety data in pregnancy
|  
|  
1. Unpredictable dose-response
2. Prolonged duration; not titratable
3. Reflex tachycardia
4. Can increase ICP
|  
|  
| Decrease in DBP > SBP; has increased HR, stroke volume and cardiac outpt; preferential vasodilation > venodilation
'''Not recommended as first-line outside of pregnancy''' due to unpredictable response and inability to titrate<ref name="AHA2024"/>


Primarily used in [[eclampsia]]/[[preeclampsia]]


|}
|}
''Note: Oral clonidine loading ("clonidine slam") is an outdated practice and is not recommended for hypertensive emergency in the ED. IV titratable agents are preferred.''<ref name="AHA2024"/>


===By Disease===
===By Disease===


====[[Aortic Dissection]]====
====[[Aortic Dissection]]====
 
*Target SBP 100-120 and HR <60 within 20 min
*Rapidly reduce sys BP to 100-120; HR 60-80 within 20min
*Beta-blockade BEFORE vasodilation to prevent reflex tachycardia
**Esmolol (preferred for titratability) OR labetalol alone
**Add nicardipine or clevidipine if BP remains elevated after adequate beta-blockade
*Adequate analgesia will decrease sympathetic drive
*Avoid volume depletion
*Avoid volume depletion
*Prevent reflex tachycardia
*Avoid nitroprusside without prior beta-blockade
**Labetalol alone
**Nitroprusside or nicardipine AFTER metoprolol or esmolol


====[[Pulmonary Edema]]====
====[[Pulmonary Edema]]====
*Reduce BP by 20-30%
*Reduce BP by 20-30%
*Nitroglycerin is drug of choice (reduces preload)
*Clevidipine or nicardipine are alternatives<ref>Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.</ref>
*Promote diuresis AFTER vasodilation
*Promote diuresis AFTER vasodilation
*Avoid beta-blockers in acute decompensated heart failure


====[[ACS]]====
====[[ACS]]====
*No more than 20-30% reduction for SBP >160
*No more than 20-30% reduction for SBP >160
*Consider NTG, beta-blocker
*Nitroglycerin preferred (increases coronary flow)
 
*Consider beta-blocker (esmolol or labetalol) if no contraindication
====[[Cocaine]]/[[Amphetamine]] Toxicitiy====
*Avoid nicardipine/clevidipine as sole agents (lack antianginal properties)


*[[Benzos]]
====[[Cocaine]]/[[Amphetamine]] Toxicity====
*Mixed α + B blockade
*[[Benzodiazepines]] first (addresses underlying sympathetic surge)
**Phentolamine '''OR''' nitroprusside AND β-blocker
*If refractory: nicardipine or clevidipine (pure vasodilators)
*Phentolamine for refractory cases
*Avoid pure beta-blockers (risk of unopposed alpha-stimulation)
*Labetalol (mixed alpha/beta) remains debated; some guidelines permit, others advise against<ref>Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345-364. doi:10.3109/15563650.2016.1142090</ref>


====[[Renal Failure]]====
====[[Renal Failure]]====
*Reduce BP by no more than 20%
*Reduce BP by no more than 20%
*Avoid nitroprusside (renal metabolism)
*Avoid nitroprusside (cyanide metabolite accumulates in renal failure)
*Labetalol or nicardipine
*Clevidipine (organ-independent metabolism), nicardipine, or fenoldopam (increases renal blood flow)
*Labetalol is an alternative


====[[Eclampsia]]/[[Pre-eclampsia]]====
====[[Eclampsia]]/[[Pre-eclampsia]]====
*Goal BP <160/110
*Labetalol, nicardipine, or hydralazine
*Magnesium sulfate for seizure prophylaxis/treatment
*Avoid ACE inhibitors/ARBs, nitroprusside (teratogenic/fetal cyanide risk)
*Definitive treatment is delivery


*Goal BP <160/110
====[[Intracerebral Hemorrhage]]====
*Labetalol or nicardipine
*Target SBP <140 mmHg, initiated within 1 hour (INTERACT3 care bundle)<ref name="INTERACT3">Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402(10395):27-40. doi:10.1016/S0140-6736(23)00806-1</ref>
*Magnesium
*INTERACT3 demonstrated improved functional outcomes (OR 0.86, 95% CI 0.76-0.97) and reduced mortality with bundled care approach<ref name="INTERACT3"/>
*Nicardipine, clevidipine, or labetalol
*Avoid nitroprusside (increases ICP)
*Care bundle also includes concurrent management of hyperglycemia, pyrexia, and anticoagulation reversal
*See [[ICH#Guidelines|current ICH guidelines]] for full recommendations


====[[Hypertensive emergency]]====
====[[CVA|Ischemic Stroke]]====
*Decrease MAP by 15-20%
*[[SAH]]: See [[Subarachnoid Hemorrhage (SAH)]]
**Avoid overly aggressive lowering
*If thrombolytic treatment is planned: goal SBP <185 and DBP <110 before administration<ref>Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211</ref>
*[[Nicardipine]] or [[labetalol]]
*If no thrombolytics: consider BP reduction only if SBP >220 or DBP >120
*Nicardipine, clevidipine, or labetalol are all effective and safe
*Clevidipine may facilitate faster door-to-thrombolytic times due to rapid onset<ref>Brehaut SS, Roche AM. Emergency department and critical care use of clevidipine for treatment of hypertension in patients with acute stroke. Crit Pathw Cardiol. 2025;24(1):e0375.</ref>


====[[CVA]]====
====[[Pheochromocytoma]]====
*Alpha-blockade first: Phentolamine
*Then add beta-blocker only after adequate alpha-blockade
*Nicardipine or clevidipine are alternatives


*[[SAH]]
==Disposition==
**See [[Subarachnoid Hemorrhage (SAH)]]
*'''Hypertensive emergency''': Admit to ICU or monitored setting for IV antihypertensive titration and close hemodynamic monitoring<ref name="AHA2025"/>
*[[ICH]]
*Asymptomatic markedly elevated BP (formerly "urgency"):
*See [[ICH#Guidelines|current guidelines]] for best practice
**Do NOT treat with IV antihypertensives in the ED<ref name="AHA2024"/>
**[[Labetalol]] or [[Nicardipine]] or [[Esmolol]]
**Restart home medications
*[[Stroke (Main)|Ischemic]]
**Assess for and address contributing factors (pain, anxiety, medication nonadherence, urinary retention)
**If thrombolytic treatment is planned then goal systolic blood pressure 185 mm Hg and diastolic blood pressure 110 mm Hg<ref>Acute Stroke Practice Guidelines for Inpatient Management of Ischemic
**Arrange close outpatient follow-up (24-72 hours)
Stroke and Transient Ischemic Attack (TIA) https://www.heart.org/idc/groups/heart-public/@wcm/@private/@hcm/documents/downloadable/ucm_309996.pdf</ref>
**Evidence suggests potential harm from acute IV treatment of asymptomatic elevated BP<ref name="AHA2024"/>
**If no thrombolytics then consider blood pressure control if SBP >220 mmHg or DBP >120 mmgHg
**[[Labetalol]] or [[Nicardipine]] are both effective and safe


====[[Pheochromocytoma]]====
*Phentolamine '''OR''' (nitroprusside AND β-blocker)


<div style="display:none">
{{MedicationDose|drug=Nicardipine|dose=5-15 mg/hr|route=IV drip|context=1st line antihypertensive|indication=Hypertensive emergency|population=Adult|onset=5-15 min|duration=4-6 hr|notes=Preferred 1st line; titratable}}
{{MedicationDose|drug=Labetalol|dose=20 mg IV bolus, double q10 min (max 300 mg) or 0.5-2 mg/min drip|route=IV|context=1st line antihypertensive|indication=Hypertensive emergency|population=Adult|onset=5-10 min|duration=3-6 hr}}
{{MedicationDose|drug=Clevidipine|dose=1-2 mg/hr, titrate by doubling q90 sec|route=IV drip|context=Antihypertensive|indication=Hypertensive emergency|population=Adult|max_dose=32 mg/hr|onset=2-4 min|notes=Ultra-short acting}}
{{MedicationDose|drug=Nitroglycerin|dose=5-200 mcg/min|route=IV drip|context=Antihypertensive (preload reduction)|indication=Hypertensive emergency|population=Adult|onset=1-5 min|notes=Preferred for ACS or pulmonary edema}}
{{MedicationDose|drug=Nitroprusside|dose=0.25-10 mcg/kg/min|route=IV drip|context=Antihypertensive|indication=Hypertensive emergency|population=Adult|onset=immediate|notes=Cyanide toxicity risk; use only when others fail}}
{{MedicationDose|drug=Esmolol|dose=500 mcg/kg bolus then 50-300 mcg/kg/min|route=IV drip|context=Antihypertensive (rate control)|indication=Hypertensive emergency|population=Adult|onset=1-2 min|duration=10-30 min|notes=Ultra-short acting beta-blocker}}
{{MedicationDose|drug=Hydralazine|dose=5-20 mg IV q4-6 hr|route=IV|context=Antihypertensive|indication=Hypertensive emergency|population=Adult|onset=10-30 min|duration=2-6 hr|notes=Unpredictable; generally avoid}}
{{MedicationDose|drug=Enalaprilat|dose=0.625-1.25 mg IV q6 hr|route=IV|context=ACE inhibitor|indication=Hypertensive emergency|population=Adult|onset=15-60 min|notes=Avoid in renal artery stenosis}}
{{MedicationDose|drug=Fenoldopam|dose=0.1-1.6 mcg/kg/min|route=IV drip|context=Antihypertensive (renal protective)|indication=Hypertensive emergency|population=Adult|onset=5-15 min|notes=DA-1 agonist; renal protective}}
{{MedicationDose|drug=Phentolamine|dose=5-15 mg IV|route=IV|context=Pheochromocytoma crisis|indication=Hypertensive emergency|population=Adult|onset=1-2 min|duration=10-30 min|notes=For catecholamine excess states}}
</div>
==See Also==
==See Also==
*[[Hypertension (main)]]
*[[Hypertension (main)]]
Line 270: Line 449:
*[[IV nitroglycerine alternatives]]
*[[IV nitroglycerine alternatives]]


==Video==
== Calculators ==
{{#widget:YouTube|id=KknXoRngPQM}}
{{MAP_Calculator}}
 
==External Links==
*[http://www.emdocs.net/hypertensive-crisis-pearls-and-pitfalls-for-the-ed-physician/ emDocs - Hypertensive Emergency: Pearls and Pitfalls for the ED Physician]
*[https://emcrit.org/ibcc/htn/ EMCrit IBCC - Hypertensive Emergency]
*[https://www.emdocs.net/2024-aha-scientific-statement-on-management-of-elevated-blood-pressure/ emDocs - 2024 AHA Scientific Statement Review]


==References==
==References==

Latest revision as of 09:24, 22 March 2026

Background


  • Definition: acute target-organ damage due to severely elevated blood pressure
    • Blood pressure is generally ≥180/110-120, but presence of end-organ damage defines disease (not absolute blood pressure number)
    • 1%-6% of all ED patients will present with severe hypertension, but less than half of those will have target organ damage[1]
    • From 2006-2013, hypertensive emergencies occurred in approximately 2 per 1000 adult ED visits[2]

Updated Terminology (AHA 2024)

The 2024 AHA Scientific Statement recommends retiring the terms "hypertensive urgency" and "hypertensive crisis"[2]

  • Hypertensive emergency: SBP ≥180 or DBP ≥110-120 mmHg with new or worsening target-organ damage
  • Asymptomatic markedly elevated BP: SBP ≥180 or DBP ≥110-120 mmHg without target-organ damage (replaces "hypertensive urgency")
  • Asymptomatic elevated BP: SBP >130 or DBP >80 mmHg without target-organ damage

Etiology

Prehospital

Clinical Features

End-Organ Dysfunction (BARKH Mnemonic)[2][4]

Use the BARKH mnemonic to systematically evaluate for target-organ damage:

Differential Diagnosis

Hypertension

Evaluation

BP Measurement

  • Ensure proper cuff size and technique before initiating treatment
  • Confirm with repeat measurement in both arms; patient should be seated, back supported, feet on floor
  • For patients receiving IV antihypertensives, arterial line monitoring is preferred for accuracy[2]

Workup

Consider any of the following based on the patient's clinical presentation[6][2]

  • CBC with peripheral smear — assess for microangiopathic hemolytic anemia (schistocytes)
  • Chem 8 — assess renal failure and possible secondary causes
  • LDH, haptoglobin — if MAHA suspected
  • Cardiac enzymes
  • Urinalysis — assess renal failure, glomerulonephritis, preeclampsia
  • ECG — LVH, ischemia
  • Ultrasound — evaluate for aortic dissection, bladder outlet obstruction, or depressed myocardial function
  • Fundoscopic Exam — evaluate for hypertensive retinopathy or papilledema
  • CXR — evaluate for pulmonary edema or widened mediastinum (dissection)
  • CT head — in hypertensive encephalopathy, may not show acute hemorrhage or other acute pathology
    • Hypertensive encephalopathy is thought to be secondary to alteration in cerebral auto-regulation leading to posterior reversible encephalopathy syndrome. Most patients will show changes on MRI, although this is not necessarily indicated in the emergency department.

Diagnosis

  • Must have evidence of end-organ dysfunction
    • High blood pressure without symptoms is NOT hypertensive emergency (see asymptomatic hypertension)
    • Symptoms such as headache, epistaxis and dizziness are not evidence of acute end-organ damage and they are not indication for acute BP reduction

Management

High blood pressure without end organ damage is NOT hypertensive emergency (see asymptomatic hypertension)

  • Goal: Lower MAP by 20-25% in the first hour[7][8]
    • Then lower gradually to 160/100 mmHg over the next 2-6 hours
    • Then cautiously to normal over the next 24-48 hours
    • Exception is aortic dissection which requires rapid reduction of systolic BP to 100-120 mmHg
  • Be careful of lowering BP in patients with CVA
  • Do NOT use IV antihypertensives for asymptomatic elevated BP, even if markedly elevated[2]

By Drug

First-Line Agents

Drug Dose Mechanism Pros Cons Notes
Nicardipine

Start 5 mg/hr IV

Increase by 2.5 mg/hr q5-15min

Max 15 mg/hr

Dihydropyridine CCB; decreases PVR

1. Effective for most hypertensive emergencies

2. Good for intracranial pathology

3. Does not increase ICP

4. Achieves target BP in >90% within 30 min (CLUE trial)[9]

1. Onset 5-15 min (slower than clevidipine)

2. Duration ~30-60 min; can accumulate

3. Reflex tachycardia possible

1. Avoid in decompensated CHF, severe aortic stenosis

2. Often considered first-line for most hypertensive emergencies

3. In CLUE subgroup with EOD, 3.65× odds of reaching target vs labetalol[10]

Clevidipine

Start 1-2 mg/hr IV

Double q2 min until approaching target

Then titrate by smaller increments q5-10 min

Max 32 mg/hr

Dihydropyridine CCB; arterial vasodilator

1. Ultra-short half-life (~1 min); truly titratable

2. Organ-independent metabolism (ester hydrolysis in blood; safe in hepatic/renal failure)

3. Rapid onset (~2-3 min)

4. Lower risk of overshoot hypotension vs nicardipine

1. Lipid emulsion vehicle (monitor triglycerides if >24hr)

2. Higher cost than nicardipine

3. Risk of rebound HTN after discontinuation

1. Avoid in soy/egg allergy, severe aortic stenosis

2. Effective in stroke, perioperative HTN[11]

3. Similar initial BP control to nicardipine; nicardipine may have more sustained control[12]

Labetalol

20 mg IV bolus initially

Then 20-80 mg IV bolus q10 min OR

0.5-2 mg/min IV infusion

Max cumulative bolus dose 300 mg

Beta > α-blocker

1. No significant change in HR or cerebral blood flow

2. Rapid onset (5-10 min)

3. Safe in pregnancy

1. Avoid in COPD, decompensated CHF, 2nd/3rd degree heart block, severe bradycardia

2. Less effective at reaching target BP than nicardipine in CLUE trial (82.5% vs 91.7%)[9]

1. Consider in ACS (when beta-blockade appropriate)

2. Consider in ischemic CVA

3. First-line in aortic dissection (provides rate and BP control)

Second-Line / Specific-Use Agents

Drug Dose Mechanism Pros Cons Notes
Esmolol

Load 250-500 mcg/kg over 1 min

Infuse 50 mcg/kg/min

If ineffective, repeat load and increase infusion by 50 mcg/kg/min up to 300 mcg/kg/min

Beta-1 selective

1. Very rapid on/offset (half-life 9 min)

2. Easily titratable

1. Avoid in COPD, decompensated CHF, severe bradycardia

2. Does not significantly lower BP alone in severe HTN

1. First-line for rate control in aortic dissection

2. Consider in ACS

3. Often used WITH a vasodilator (nicardipine/clevidipine)

Nitroglycerin Start 5 mcg/min IV; titrate up to 200 mcg/min Venodilator > arteriodilator

1. Rapid onset/offset

2. Increases coronary blood flow

3. Reduces preload (ideal for pulmonary edema)

1. Reflex tachycardia

2. Headache common

3. Tachyphylaxis with prolonged use

Drug of choice in patients with cardiac ischemia, LV dysfunction, or pulmonary edema

Nitroprusside

0.3-0.5 mcg/kg/min IV initial

Max 2 mcg/kg/min (some refs up to 10)

Arterial > venodilator

1. Very effective

2. Immediate onset/offset

1. Cyanide toxicity (especially with renal/hepatic failure or prolonged use)

2. Coronary steal

3. Increased ICP

4. Requires light-protected tubing

Generally considered second- or third-line; safer alternatives preferred (nicardipine, clevidipine)

Avoid in liver/renal failure, increased ICP, pregnancy

Phentolamine

5-15 mg IV bolus q5-15 min OR

0.2-0.5 mg/min IV infusion

α-blocker Rapid onset Reflex tachycardia

Used for catecholamine-induced hypertension (pheochromocytoma, sympathomimetic toxicity)

Fenoldopam

0.1-0.3 mcg/kg/min IV

Titrate q15 min

Max 1.6 mcg/kg/min

Dopamine-1 agonist

1. Increases renal blood flow and natriuresis

2. No toxic metabolites

1. Reflex tachycardia

2. Avoid in glaucoma (increases IOP)

Consider in hypertensive emergency with AKI/renal failure[13]

Enalaprilat Bolus 1.25 mg IV over 5 min q6hr, titrate at 30 min intervals to max of 5 mg q6hr ACE inhibitor; decreases HR, SV, systemic arterial pressure Does not impair cerebral blood flow Variable and unpredictable response

1. Consider in high-renin states, CHF

2. Avoid in pregnancy

3. Limited role in ED

Hydralazine

10-20 mg slow IV/IM q4-6 hr PRN

Max 40 mg/dose

Direct arterial vasodilator; onset 10-30 min, duration 2-4 hrs Extensive safety data in pregnancy

1. Unpredictable dose-response

2. Prolonged duration; not titratable

3. Reflex tachycardia

4. Can increase ICP

Not recommended as first-line outside of pregnancy due to unpredictable response and inability to titrate[2]

Primarily used in eclampsia/preeclampsia

Note: Oral clonidine loading ("clonidine slam") is an outdated practice and is not recommended for hypertensive emergency in the ED. IV titratable agents are preferred.[2]

By Disease

Aortic Dissection

  • Target SBP 100-120 and HR <60 within 20 min
  • Beta-blockade BEFORE vasodilation to prevent reflex tachycardia
    • Esmolol (preferred for titratability) OR labetalol alone
    • Add nicardipine or clevidipine if BP remains elevated after adequate beta-blockade
  • Adequate analgesia will decrease sympathetic drive
  • Avoid volume depletion
  • Avoid nitroprusside without prior beta-blockade

Pulmonary Edema

  • Reduce BP by 20-30%
  • Nitroglycerin is drug of choice (reduces preload)
  • Clevidipine or nicardipine are alternatives[14]
  • Promote diuresis AFTER vasodilation
  • Avoid beta-blockers in acute decompensated heart failure

ACS

  • No more than 20-30% reduction for SBP >160
  • Nitroglycerin preferred (increases coronary flow)
  • Consider beta-blocker (esmolol or labetalol) if no contraindication
  • Avoid nicardipine/clevidipine as sole agents (lack antianginal properties)

Cocaine/Amphetamine Toxicity

  • Benzodiazepines first (addresses underlying sympathetic surge)
  • If refractory: nicardipine or clevidipine (pure vasodilators)
  • Phentolamine for refractory cases
  • Avoid pure beta-blockers (risk of unopposed alpha-stimulation)
  • Labetalol (mixed alpha/beta) remains debated; some guidelines permit, others advise against[15]

Renal Failure

  • Reduce BP by no more than 20%
  • Avoid nitroprusside (cyanide metabolite accumulates in renal failure)
  • Clevidipine (organ-independent metabolism), nicardipine, or fenoldopam (increases renal blood flow)
  • Labetalol is an alternative

Eclampsia/Pre-eclampsia

  • Goal BP <160/110
  • Labetalol, nicardipine, or hydralazine
  • Magnesium sulfate for seizure prophylaxis/treatment
  • Avoid ACE inhibitors/ARBs, nitroprusside (teratogenic/fetal cyanide risk)
  • Definitive treatment is delivery

Intracerebral Hemorrhage

  • Target SBP <140 mmHg, initiated within 1 hour (INTERACT3 care bundle)[16]
  • INTERACT3 demonstrated improved functional outcomes (OR 0.86, 95% CI 0.76-0.97) and reduced mortality with bundled care approach[16]
  • Nicardipine, clevidipine, or labetalol
  • Avoid nitroprusside (increases ICP)
  • Care bundle also includes concurrent management of hyperglycemia, pyrexia, and anticoagulation reversal
  • See current ICH guidelines for full recommendations

Ischemic Stroke

  • SAH: See Subarachnoid Hemorrhage (SAH)
  • If thrombolytic treatment is planned: goal SBP <185 and DBP <110 before administration[17]
  • If no thrombolytics: consider BP reduction only if SBP >220 or DBP >120
  • Nicardipine, clevidipine, or labetalol are all effective and safe
  • Clevidipine may facilitate faster door-to-thrombolytic times due to rapid onset[18]

Pheochromocytoma

  • Alpha-blockade first: Phentolamine
  • Then add beta-blocker only after adequate alpha-blockade
  • Nicardipine or clevidipine are alternatives

Disposition

  • Hypertensive emergency: Admit to ICU or monitored setting for IV antihypertensive titration and close hemodynamic monitoring[7]
  • Asymptomatic markedly elevated BP (formerly "urgency"):
    • Do NOT treat with IV antihypertensives in the ED[2]
    • Restart home medications
    • Assess for and address contributing factors (pain, anxiety, medication nonadherence, urinary retention)
    • Arrange close outpatient follow-up (24-72 hours)
    • Evidence suggests potential harm from acute IV treatment of asymptomatic elevated BP[2]


Nicardipine 5-15 mg/hr IV drip (onset 5-15 min, duration 4-6 hr) — Preferred 1st line; titratable Labetalol 20 mg IV bolus, double q10 min (max 300 mg) or 0.5-2 mg/min drip IV (onset 5-10 min, duration 3-6 hr) Clevidipine 1-2 mg/hr, titrate by doubling q90 sec IV drip (onset 2-4 min) (max 32 mg/hr) — Ultra-short acting Nitroglycerin 5-200 mcg/min IV drip (onset 1-5 min) — Preferred for ACS or pulmonary edema Nitroprusside 0.25-10 mcg/kg/min IV drip (onset immediate) — Cyanide toxicity risk; use only when others fail Esmolol 500 mcg/kg bolus then 50-300 mcg/kg/min IV drip (onset 1-2 min, duration 10-30 min) — Ultra-short acting beta-blocker Hydralazine 5-20 mg IV q4-6 hr IV (onset 10-30 min, duration 2-6 hr) — Unpredictable; generally avoid Enalaprilat 0.625-1.25 mg IV q6 hr IV (onset 15-60 min) — Avoid in renal artery stenosis Fenoldopam 0.1-1.6 mcg/kg/min IV drip (onset 5-15 min) — DA-1 agonist; renal protective Phentolamine 5-15 mg IV IV (onset 1-2 min, duration 10-30 min) — For catecholamine excess states

See Also

Calculators

Mean Arterial Pressure (MAP)

Mean Arterial Pressure (MAP)
Parameter Value
Systolic BP (mmHg)
Diastolic BP (mmHg)
MAP mmHg
Interpretation
70–105 Normal — Adequate perfusion pressure.
<65 Low — Risk of end-organ hypoperfusion. Target MAP ≥65 in septic shock (SSC 2021).
>105 Elevated — Consider antihypertensive therapy based on clinical context.
References
  • Formula: MAP = DBP + (SBP – DBP) / 3
  • Rhodes A, et al. Surviving Sepsis Campaign: International Guidelines. Intensive Care Med. 2017;43(3):304-377. PMID 28101605.

External Links

References

  1. ↑ Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252. doi:10.1161/01.HYP.0000107251.49515.c2
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Bress AP, Anderson TS, Flack JM, et al. The management of elevated blood pressure in the acute care setting: a scientific statement from the American Heart Association. Hypertension. 2024;81(8):e94-e106. doi:10.1161/HYP.0000000000000238
  3. ↑ Cienki JJ, DeLuca LA. Agreement between emergency medical services and expert blood pressure measurements. J. Emerg Med. 2012;43(1):64-68.
  4. ↑ Levy PD. Hypertensive Emergencies — On the Cutting Edge. EMCREG - International. 2011. 19-26.
  5. ↑ Cremer A, Amraoui F, Lip GY, et al. From malignant hypertension to hypertension-MOD: a modern definition for an old but still dangerous emergency. J Hum Hypertens. 2016;30(8):463-466. doi:10.1038/jhh.2015.82
  6. ↑ 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013;31(10):1925-1938.
  7. ↑ 7.0 7.1 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Hypertension. 2025;82(10):e212-e316. doi:10.1161/HYP.0000000000000249
  8. ↑ Elliott WJ. Clinical features in the management of selected hypertensive emergencies. Prog Cardiovasc Dis. 2006;48(5):316-325. doi:10.1016/j.pcad.2006.02.004
  9. ↑ 9.0 9.1 Peacock WF, Varon J, Baumann BM, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care. 2011;15(3):R157. doi:10.1186/cc10289
  10. ↑ Levy PD, Mahn JJ, Miller J, et al. Intravenous nicardipine and labetalol use in hypertensive patients with signs or symptoms suggestive of end-organ damage in the emergency department: a subgroup analysis of the CLUE trial. BMJ Open. 2013;3(3):e002338. doi:10.1136/bmjopen-2012-002338
  11. ↑ Brehaut SS, Roche AM. Emergency department and critical care use of clevidipine for treatment of hypertension in patients with acute stroke. Crit Pathw Cardiol. 2025;24(1):e0375. doi:10.1097/HPC.0000000000000375
  12. ↑ Storey C, Pouliot J. Evaluation of the efficacy and safety of nicardipine versus clevidipine for blood pressure control in hypertensive crisis. J Emerg Med. 2024;67(3):e267-e275.
  13. ↑ Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.
  14. ↑ Fink JT, Singh I. Treatment of hypertensive emergencies. Proc (Bayl Univ Med Cent). 2017;30(2):214-216.
  15. ↑ Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345-364. doi:10.3109/15563650.2016.1142090
  16. ↑ 16.0 16.1 Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet. 2023;402(10395):27-40. doi:10.1016/S0140-6736(23)00806-1
  17. ↑ Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418. doi:10.1161/STR.0000000000000211
  18. ↑ Brehaut SS, Roche AM. Emergency department and critical care use of clevidipine for treatment of hypertension in patients with acute stroke. Crit Pathw Cardiol. 2025;24(1):e0375.
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