Hypertensive Emergency and Severe Hypertension: What to Treat, Who to Treat, and How to

Hypertensive emergency is a clinical syndrome of rapidly progressive end-organ damage associated with a significant elevation of blood pressure. The immediate reduction of blood pressure using potent intravenous (IV) agents is indicated to reduce the mortality rate, which ranges historically as high as 90%. Virtually all episodes of hypertensive emergency are associ-ated with a diastolic blood pressure (DBP) O120 mm Hg; however, most patients who present with severe hypertension do not have a hypertensive emergency. It is crucial to recognize that not only will these patients not ben-efit from aggressive normalization of blood pressure but also there can be substantial morbidity caused by overly rapid decreases in blood pressure in patients who do not have rapidly evolving end-organ damage. Distin-guishing between these two groups of patients is the first step in the safe management of significantly hypertensive patients. A thorough history, physical examination, and assessment of readily available laboratory tests will efficiently identify the minority of patients who need intensive treat-ment. Unfortunately, unclear terminology for clinically describing these patients is often a source of confusion and can present a barrier to correct management. As medical therapy grows more powerful, the attendant risks also grow in consequence. Definitions that served in the past now need re-finement, based on the available evidence of the benefits and risks o