Snapshot A 58-year-old African American male presents with chest pain and dyspnea. His blood pressure is found to be 210/125 mmHg. Urinalysis indicates proteinuria. Fundoscopy is notable for retinal arteriolar narrowing, flame hemorrhages, and cotton-wool spots. Introduction Hypertensive emergency > 180/120 mmHg in addition to end-organ damage can occur in the presence or absence of preexisting chronic hypertension this is in contrast to hypertensive urgency, which is when there is severe blood pressure elevation (≥180/110 mmHg) in the absence of end-organ damage Malignant HTN severely elevated blood pressure resulting in end-organ damage that typically involves the retina (i.e., papilledema). other organs may be included (i.e., brain, heart, kidneys) Presentation and Evaluation Symptoms a common presentation of patients with hypertensive emergency includes cerebral infarction hypertensive encephalopathy pulmonary edema heart failure Physical Examshows BP > 180/120 mmHg with associated signs and symptoms of end-organ damage signs of heart failure wheezes or rales, suggestive of pulmonary edema abdominal bruits, suggestive or renal artery stenosis seizures, delirium, stupor, suggestive of CNS involvement fundoscopy might demonstrate retinal arteriolar changes e.g., "copper-wiring" and/or "silver-wiring" arteriolar narrowing "onion-skinning" hyperplasia on biopsy retinal hemorrhages papilledema cotton-wool spots Treatment Gradually reduce mean arterial pressure to about ~ 10-20% in the first hour there are exceptions (e.g., aortic dissection) Intravenous anti-hypertensive agents sodium nitroprusside, nitroglycerin, labetalol, nicardipine, hydralazine (vasodilation), and esmolol