Hypertensive Crisis in an Era of Escalating Health Care Changes

Theresa P. Yeo; Sherry A. Burrell


Journal for Nurse Practitioners. 2010;6(5):338-346. 

In This Article

Abstract and Introduction


Over the past decade, the prevalence of hypertension (HTN) in the United States has escalated, and today's acute care advance practice nurses (APNs) are likely to encounter more patients experiencing a hypertensive crisis. In this article, we highlight the rising prevalence and financial burden of HTN. Causes of hypertensive crisis, the clinical differences between HTN emergency and HTN urgency, and current recommendations for crisis management are discussed. Managing primary HTN is critical to preventing the development of hypertensive crisis.


Hypertension (HTN) is a common chronic condition, affecting 29% of Americans 18 years and older.[1] Over the past decade, the prevalence of HTN in the United States has been steadily rising, corresponding with the increasing number of older adults, obese Americans, and uninsured persons.[2] Hypertensive crises, which include hypertensive urgency and hypertensive emergency, are encountered by acute care advanced practice nurses (APNs) in a wide variety of clinical settings. Successful management of these conditions requires prompt identification and assessment, an accurate differential diagnosis, and appropriate treatment to prevent permanent organ damage. Moreover, sudden increases in blood pressure (BP) are often preventable, resulting from untreated HTN, inadequate management of existing HTN, or lack of patient adherence to antihypertensive therapies. The purpose of this article is two-fold, first to provide APNs with the tools for prompt recognition, evaluation, and management of severely elevated BP in the acute care setting; and second, to discuss the responsibility of the acute care APN in the prevention of hypertensive crises.

The Joint National Commission on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) classification system is based upon the level of BP elevation.[3] The JNC-7 defines a systolic BP of between 120 and 139 mmHg or a diastolic BP of 80 to 89 mmHg as pre-HTN. Whereas a systolic BP of 140 to 159 mm Hg or a diastolic BP of 90 to 99 mmHg is considered stage I hypertension, and a systolic BP ≥ 160 or a diastolic BP ≥ 100 mmHg is classified as stage II hypertension. Hypertensive crisis is an umbrella term for acute, severe elevations in BP, which comprise 2 conditions on a continuum: hypertensive urgency and hypertensive emergency. Hypertensive urgency is severely elevated BP (diastolic BP ≥ 120 mmHg) with no obvious, acute target-organ damage (TOD). In contrast, hypertensive emergency is the most serious, but least common form of hypertensive crisis, representing only 5% of cases.[3] It is differentiated from hypertensive urgency by evidence of TOD, which may include signs and symptoms of stroke, papilledema, heart failure, or aortic dissection (Table 1).