High Blood Pressure & Cardiovascular Prevention

https://doi.org/10.1007/s40292-018-0263-2

REVIEW ARTICLE

Definitions and Epidemiological Aspects of Hypertensive Urgencies

and Emergencies
Anna Paini1,2 · Carlo Aggiusti1,2 · Fabio Bertacchini1,2 · Claudia Agabiti Rosei1,2 · Giulia Maruelli1,2 · Chiara Arnoldi1,2 ·
Sara Cappellini1,2 · Maria Lorenza Muiesan1,2 · Massimo Salvetti1,2 

Received: 19 March 2018 / Accepted: 6 June 2018

© Springer International Publishing AG, part of Springer Nature 2018

Abstract
Acute blood pressure (BP) elevation represents a frequent reason of concern for clinicians in everyday clinical practice. The
terms “hypertensive emergencies” and “hypertensive urgencies” may be used in order to better define the so called “hyper-
tensive crises”. A hypertensive emergency may be defined as a condition characterized by an acute and severe elevation of
blood pressure (BP) associated to a new onset or worsening organ damage (OD). A hypertensive urgency may be defined as
a condition characterized by an isolated elevation of BP values without evidence of acute hypertensive OD. This article will
review the definition, the prevalence, and the prognostic implications of hypertensive emergencies and urgencies.

Keywords  Hypertension emergencies · Hypertension urgencies · Definition · Epidemiology

1 Introduction syndromes, pulmonary edema, but also aortic dissection,

Management of acute blood pressure (BP) elevation is not
uncommon in everyday clinical practice, and may represent
a concern for general practitioners and specialists. Appro-
priate management of acute BP elevation is crucial in order
to prevent severe organ damage but also in order to avoid
unnecessary hospitalizations. Current hypertension Guide-
lines have suggested to replace the term “hypertensive cri-
sis” with ‘hypertensive emergencies’ or ‘hypertensive urgen-
cies’. Both the European Society of Hypertension [1] and
the American Society of Hypertension [2] have defined a
‘hypertensive emergency’ as a condition characterized by
an acute and severe elevation of BP associated to a new
onset or worsening organ damage (OD) (Fig. 1). Severe
BP elevation associated with hypertensive encephalopa-
thy, acute stroke, intracranial hemorrhage, acute coronary
This article is part of the topical collection on Hypertension
Urgencies & Emergencies.
* Massimo Salvetti
massimo.salvetti@unibs.it
1
Department of Clinical and Experimental Sciences,
University of Brescia, Brescia, Italy
2
C/O 2ª Medicina ASST Spedali Civili di Brescia, Piazzale
Spedali Civili 1, 25123 Brescia, Italy
acute or rapidly progressing renal failure, sympathetic cri-
ses (i.e. cocaine toxicity/pheochromocytoma), eclampsia or
severe pre-eclampsia all represent hypertensive emergen-
cies, i.e. conditions in which the elevation of BP values may
contribute to the development and/or worsening of organ
damage [1–3]. ‘Malignant hypertension’ may be considered
a hypertensive emergency which involves the retinal vascu-
lature (bilateral retinal hemorrhages and exudates, with or
without papilledema) and the kidney (renal failure). It is a
rare condition (less than 1% of hypertensives), characterized,
by an histological point of view, by a fibrinoid arteriolar
necrosis in many vascular beds (especially the kidneys).
The degree of BP elevation suggested by these Guide-
lines for the definition of hypertensive emergencies is
> 180 mmHg for systolic (SBP) or 120 mmHg for dias-
tolic BP (DBP), respectively. Some Authors have proposed
slightly different cutoffs, but it should be kept in mind that a
rapid rise of BP might be more harmful than the absolute BP
values. Therefore the rate of BP rise should be taken in ade-
quate consideration in these conditions. Zampaglione et al.
in 1996, in their description of the epidemiological aspects
of hypertensive emergencies and urgencies used a BP cut-
off of > 120 mmHg DBP [4]. More recently, in the STAT
registry (Studying the Treatment of Acute hypertension),
an US registry that enrolled 1.588 consecutive patients,
the inclusion criteria for defining the presence of an acute

Vol.:(0123456789)
 A. Paini et al.

Fig. 1  Definition of hyperten-
sive emergencies and urgencies Definition BP values

Severe and acute elevation of

Hypertensive blood pressure associated to a
Emergencies new onset or worsening organ
damage* SBP>180 mmHg
and/or
Elevation of blood pressure DBP>120 mmHg
Hypertensive values without clinical, laboratory
Urgencies or instrumental evidence of acute
hypertensive organ damage*

* Organ damage: hypertensive encephalopathy, acute stroke, intracranial hemorrhage, acute coronary
syndromes, pulmonary edema, aorc dissecon, acute or rapidly progressing renal failure, sympathec
crises (i.e. cocaine toxicity/pheochromocytoma), eclampsia or severe pre-eclampsia

severe hypertension was more than 180 mmHg for SBP and/
or more than 110 mmHg for DBP, except for patients with
subarachnoid hemorrhage in which a lower threshold was
used (SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg) [5].
A ‘hypertensive urgency’ may be defined as a condition
characterized by an isolated elevation of BP values with-
out clinical, laboratory or instrumental evidence of acute
hypertensive OD (Fig. 1). Hypertensive urgencies are often
associated to a withdrawal of antihypertensive treatment in
patients with preexisting hypertension. It must be consid-
ered that a large overlap may exist between hypertensive
urgencies and ‘uncontrolled hypertension’, in which patients
have chronically elevated BP values, often due to poor anti-
hypertensive treatment adherence. Also other factors, such
as anxiety, panic attacks, pain, venous epistaxis or alcohol
withdrawal may lead to rapid increases of BP values (pseudo
hypertensive crises); in these conditions appropriate treat-
ment of factors triggering acute BP elevation may lead to a
significant reduction of BP values [6]. On the other hand,
patients classified as having a hypertensive urgency after an
initial workup may show a rapid worsening of clinical condi-
tions, and therefore the correct definition of these conditions
requires an accurate observation during the first hours. In
other words, physicians should pay attention to the possi-
ble evolution of a hypertensive urgency into a hypertensive
emergency, and this is particularly important in view of
the therapeutic implications of a diagnosis of hypertensive
emergency. In fact, in patients with hypertensive urgencies,
BP should be lowered gradually and usually normalized in
24–48 h with administration of oral drugs (antihyperten-
sive drugs and, if appropriate, treatment of anxiety), in most
cases hospitalization is not indicated and a strict ambulatory
follow-up visit is recommended. On the contrary, patients
with hypertensive emergencies should be promptly admit-
ted to an intensive care unit for continuous BP monitoring
and appropriate treatment. Blood pressure should be low-
ered more rapidly (except in patients with a cerebrovascular
event, in which a more cautious approach is advisable), with
a reduction of BP of no more than 20–25% within the first
minutes and up to one or 2 h, followed by a cautious reduc-
tion thereafter, using intravenous drugs [3, 7].
2 Epidemiology
Epidemiological data on incidence and prevalence of
patients referred to the Emergency Department (ED)
hypertensive emergencies and/or urgencies are limited
both in general population and emergency departments. It
has been estimated that hypertensive emergencies occur
in up to 2–3% of hypertensive patients [4, 8, 9]. In the
study published by Zampaglione et al. [4], who described
the characteristics of 14,209 patients admitted to an ED in
Northern Italy during a period of 12 months, the number
of all medical urgencies-emergencies was 1634 (11.5%),
and, among them, the prevalence of hypertensive cri-
ses was of 27%; therefore, “hypertensive crises” repre-
sented 3.16% of all admissions to the ED. The Authors
also observed that hypertensive urgencies are much more
frequent than hypertensive emergencies (76 and 24%,
respectively). Analyzing the distribution by age class and
sex, they showed that urgencies and emergencies tended
to occur at younger age in males than in females (51–60
versus 61–70 years of age and 61–70 versus 81–90 years
of age, respectively). At variance with the high preva-
lence described in this study, others investigators found a
lower prevalence of hypertensive crises, with a reported
rate between 0.45 and 1.45% [10–13]. This discrepancy
might be explained by the inclusion, in the Italian study,
of cases of hypertensive pseudo-crises, which may mimic
a hypertensive urgency. More recently, in a multicenter
study [14] involving more than three-hundred thousand
patients, the incidence of hypertensive crises was of
4.6/1000 (i.e. 0.46%) among all patients admitted to EDs
Hypertensive Urgencies and Emergencies
(95% CI 4.4–4.9); about one quarter (25.3%) had a hyper-
tensive emergency. Figure 2 describes the prevalence of
hypertensive emergencies and urgencies reported in dif-
ferent studies [4, 5, 12, 14]. A slightly greater prevalence
of hypertensive crises was observed in women, although
this value probably represents an underestimation of the
real phenomenon, because most patients with eclampsia or
preeclampsia are usually admitted directly to the obstetrics
EDs [10–13].
Among patients admitted to the ED for hypertensive an
emergency or urgency, a higher prevalence of a previous
diagnosis of hypertension was described, ranging from 75
to 88% of patients [13] and suggesting that withdrawal
and/or non-compliance to chronic antihypertensive treat-
ment represents a potential risk factor for hypertensive
crises [15].
In the United States the incidence of adult ED vis-
its for hypertensive crises increased between 2000 and
2007, ranging from 0.16 to 0.19% of all admissions [16],
although the mortality rates decreased significantly (odds
ratio 0.85, 95% confidence interval 0.79–0.92). This trend
has been confirmed also in the period from 2006 to 2013
[17], with an increase incidence of 16.2%, although hyper-
tensive emergencies remained a rare diagnosis accounting
for less than 2 in 1000 adult ED visits in 2013.
In the study published by Zampaglione et al. the most
frequent signs and symptoms of presentation were head-
ache and epistaxis in hypertensive urgencies (22 and 17%,
respectively), whereas chest pain, dyspnea, and neurologi-
cal deficit were the most frequent signs in hypertensive
emergencies (27, 22, and 21%). Similarly, in the STAT
registry [5], the most frequent signs and symptoms of pres-
entation in patients with acute severe hypertension were
Fig. 2  Prevalence of hyperten- 100
sive emergencies and urgencies %
reported in different studies 90
80 76
70
60
50
40
30 24
20
10
0
Zampaglione Vilela-Marn STAT registry
1996 [4]
shortness of breath (29%), chest pain (26%), headache
(23%), altered mental status (20%) and focal neurologic
deficit (11%).
When considering the type of organ damage in hyper-
tensive emergencies, available data indicate that the most
frequent are cerebral infarction and acute pulmonary
oedema (24 and 23%, respectively), followed by hyperten-
sive encephalopathy (16%) and cerebral hemorrhage, which
accounted for only 4.5% [4].
The future risk of cardiovascular events is high in patients
with prior admission for hypertensive emergencies and
urgencies [4, 8, 9]. In a US study including a total of 456,259
patients hospitalized with the diagnosis of hypertensive
emergency from 2000 to 2007 the stronger predictors of
mortality were increasing age, male sex and a higher Charl-
son comorbidity index [16]. In the STAT registry, a 6.9%
hospital mortality and 37% 90-day readmission rate were
reported; hospital deaths were more frequent in patients with
intracranial hemorrhage (20%). In the same study the predic-
tors of readmissions for hypertension were poor adherence
to the antihypertensive regimen, substance abuse and end
stage renal disease [5].
The short-term outcomes of hypertensive urgencies have
been analyzed in a retrospective cohort study in which 852
were seen in an outpatient office [18]. In this population
the rate of major adverse cardiovascular events during a
6-months follow-up was low (< 1%). On the opposite, in
the study by Vlcek et al. [19], who analyzed the risk of car-
diovascular events in patients admitted for an hypertensive
urgency to the ED of a large hospital in Austria, the fre-
quency of cardiovascular events was significantly greater in
patients with hypertensive urgencies as compared to control
patients with hypertension stage 1 or 2 (n = 88 versus n = 42;
75
69 70
60
40
31 30
25
Pinna Mean
2004 [11] 2009 [5] 2014 [13] Prevalence
Emergencies
Urgencies

p = 0.005). At Cox analysis, the independent predictors of
cardiovascular events were age and hypertensive urgencies
[19].
3 Conclusion
Hypertensive emergencies and urgencies represent a fre-
quent challenge for physicians in everyday clinical practice.
Rapid and careful assessment of the clinical presentation is
crucial in order to allow prompt recognition of life threaten-
ing conditions. Epidemiological data suggest an increasing
prevalence of both hypertensive emergencies and urgen-
cies. However, more studies are warranted in order to more
clearly establish the actual prevalence and incidence of dif-
ferent clinical presentations of hypertensive emergencies and
urgencies.
Compliance with Ethical Standards  JP. Hypertensive crisis profile. Prevalence and clinical presenta-
Funding  All the Authors declare that they have no funding to declare.
Conflict of interest  All the Authors declare that they have no conflict
of interest to declare.
Human and animal rights statement  All the Authors declare that this
article does not contain any studies with human participants or animals
performed by any of the authors.
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