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cardio.hypertensive-emergency.core.v1PRODUCTION
cardio.hypertensive-emergency.core.v1

Hypertensive emergency

cardiologyacuteadult
Hard-required inputs
0 / 8
Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Differentiate emergency (end-organ damage → IV/ICU) vs urgency (no damage → oral/days) per ACC/AHA 2017

Inputs
3
Actions
0
Advance rule
Set
Advance when

emergency vs urgency classified

Patient inputs (14)

Pregnancy, age extremes alter agent selection (ACOG 2019; ACC/AHA 2017)

AKI — hypertensive AKI / scleroderma renal crisis (ACC/AHA 2017)

Cardiac end-organ damage (ACC/AHA 2017; Vaughan JAMA 2000)

LVH, ischemia (ACC/AHA 2017; ESC/ESH 2023)

Defines emergency threshold ≥180 + titration target (ACC/AHA 2017; Whelton 2018)

Defines emergency threshold ≥120 + titration target (ACC/AHA 2017; Whelton 2018)

Stroke / ICH / hypertensive encephalopathy / PRES (Vaughan JAMA 2000; AHA/ASA 2022)

Aortic dissection target HR <60 before vasodilator (ACC/AHA 2022 Aortic)

Eclampsia/preeclampsia targets + MgSO4 + delivery curative (ACOG 2019; Magee NEJM 2022)

Sympathomimetic crisis — phentolamine; AVOID β-monotherapy (ACC/AHA 2017; Vaughan JAMA 2000)

Reinstitute the abruptly withdrawn agent (ACC/AHA 2017; JNC 8, James 2014)

Tissue perfusion in shock states (ESC/ESH 2023)

Pulmonary edema / mediastinal widening (ACC/AHA 2017)

ACS, dissection, pulmonary edema (ACC/AHA 2017; Vaughan JAMA 2000)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningaortic_dissection_acute — ACC/AHA 2022
    Tearing pain + inter-arm gradient + mediastinal widening (ACC/AHA 2022 Aortic)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningich_with_htn_emergency — AHA/ASA 2022
    CT head shows ICH with SBP >140 (Anderson NEJM 2023; AHA/ASA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeclampsia_severe_features — ACOG 2019
    Pregnancy + BP ≥160/110 + severe features — HA, vision, RUQ, AMS, low platelets, AKI, transaminitis (ACOG 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningscleroderma_renal_crisis — Vaughan JAMA 2000
    dcSSc + abrupt malignant HTN + AKI ± MAHA (Vaughan JAMA 2000)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningflash_pulmonary_edema_with_emergency — ACC/AHA 2017
    Severe HTN + pulmonary edema + respiratory distress (ACC/AHA 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningencephalopathy_progression_to_coma — Vaughan Lancet 2000
    Hypertensive encephalopathy progressing to coma / GCS <8 / posturing (Vaughan Lancet 2000 PMID 10972386; ACC/AHA 2025)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdissection_extension_on_serial_ct — ACC/AHA 2022 Aortic
    New / extended dissection flap on serial CT or new branch malperfusion (ACC/AHA 2022 Aortic PMID 36322642; IRAD PMID 17709637)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpreeclampsia_progression_to_eclampsia — ACOG 222
    Severe pre-eclampsia progressing to eclampsia (seizure) (ACOG Practice Bulletin 222 2019; Magee CHIPS NEJM 2015 PMID 25629739)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnew_mi_on_serial_troponin — ACC/AHA 2017+2025
    New positive troponin or dynamic troponin trend on serial draws in HTN emergency (ACC/AHA 2017+2025; 4th Universal MI Definition)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresympathetic_crisis — ACC/AHA 2017
    Cocaine / methamphetamine / pheochromocytoma + severe HTN (ACC/AHA 2017; Vaughan JAMA 2000)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypertensive_urgency_no_organ_damage — ACC/AHA 2017+2025
    SBP ≥180/120 without end-organ damage (ACC/AHA 2017+2025; ACEP 2024 Policy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaki_on_admission_with_htn_emergency — ACC/AHA 2017+2025
    New AKI (Cr rise ≥0.3 or eGFR <30) on admission in HTN emergency — avoid ACEi acutely (ACC/AHA 2017+2025; KDIGO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Hypertensive emergency — end-organ phenotype-specific IV agents + MAP reduction strategy (ACC/AHA 2017+2025; ESC/ESH 2024)
axis: htn_emergency_syndrome_specificstep 1 - Phenotype 1 — General hypertensive encephalopathy (cerebral edema / AMS / severe HA / papilledema)
Selected step "Phenotype 1 — General hypertensive encephalopathy (cerebral edema / AMS / severe HA / papilledema)" — BP ≥180/120 + AMS / severe HA / papilledema / vision change without focal deficit (ACC/AHA 2017+2025; Vaughan Lancet 2000 PMID 10972386)
  • nicardipine
    first line
    DHP_CCB
    5 mg/h IV, titrate by 2.5 mg/h q5–15 min, max 15 mg/h • IV • continuous
    triggers: hypertensive_encephalopathy
    ACC/AHA 2025 first-line — MAP ↓ ≤25% in first hour; SBP <140 within 6 h target (Vaughan Lancet 2000 PMID 10972386)
    rxcui 7396
  • clevidipine
    first line
    DHP_CCB_short_acting
    1–2 mg/h IV, titrate • IV • continuous
    triggers: volume_overload_concern_with_encephalopathy
    Short half-life allows tight control; lipid emulsion (avoid egg/soy allergy)
    rxcui 233603
  • labetalol
    second line
    mixed_alpha_beta_blocker
    20 mg IV q10 min (max 300 mg) OR 0.5–2 mg/min infusion • IV • bolus or infusion
    triggers: encephalopathy_with_tachycardia
    No reflex tachy; mixed α/β useful when sympathetic drive is high (ACC/AHA 2017+2025)
    rxcui 6185

outpatient playbook — drug actions (3)

  1. 1. continue 4-tier oral regimen at week-1 dose
    rxcui 17767
    Amlodipine 5–10 + lisinopril 10–40 + chlorthalidone 12.5–25 • PO • daily
    trigger: Stable BP at d/c
    Maintain ACC/AHA 2017+2025 ladder; tune by home BP trend
  2. 2. first up-titration of ARB/ACEi if BP >130/80
    rxcui 29046
    Lisinopril 10 → 20 → 40 mg daily (or losartan 50 → 100 mg) • PO • daily
    trigger: BP not at <130/80 + K <5.0 + eGFR stable
    STRONG-HF analog intensive titration; SPRINT (PMID 26551272) <130 SBP anchor
  3. 3. add MRA if resistant phenotype
    rxcui 9997
    Spironolactone 12.5 → 25 mg daily • PO • daily
    trigger: Resistant + K <5 + eGFR ≥30
    PATHWAY-2 4th-line option (ACC/AHA 2017+2025)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: SBP >180 and/or DBP >120 (ACC/AHA 2017; Whelton 2018); Headache, chest pain, dyspnea, vision change, focal deficit, seizure (Vaughan JAMA 2000); CT head ICH / aortic dissection / pulmonary edema (AHA/ASA 2022; ACC/AHA 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hypertensive emergency** (cardio.hypertensive-emergency.core.v1).
Phenotype framing: Syndrome-specific (dissection / ICH / ischemic stroke / encephalopathy / PRES / eclampsia / acute pulm edema / SRC / sympathetic crisis) per Vaughan JAMA 2000
Scope: Differentiate emergency (end-organ damage → IV/ICU) vs urgency (no damage → oral/days) per ACC/AHA 2017

No severity triggers fired against current inputs.

Plan

Regimen axis: **Hypertensive emergency — end-organ phenotype-specific IV agents + MAP reduction strategy (ACC/AHA 2017+2025; ESC/ESH 2024)** — step "Phenotype 1 — General hypertensive encephalopathy (cerebral edema / AMS / severe HA / papilledema)".
1. nicardipine 5 mg/h IV, titrate by 2.5 mg/h q5–15 min, max 15 mg/h IV continuous (DHP_CCB, first line) — ACC/AHA 2025 first-line — MAP ↓ ≤25% in first hour; SBP <140 within 6 h target (Vaughan Lancet 2000 PMID 10972386)
2. clevidipine 1–2 mg/h IV, titrate IV continuous (DHP_CCB_short_acting, first line) — Short half-life allows tight control; lipid emulsion (avoid egg/soy allergy)
3. labetalol 20 mg IV q10 min (max 300 mg) OR 0.5–2 mg/min infusion IV bolus or infusion (mixed_alpha_beta_blocker, second line) — No reflex tachy; mixed α/β useful when sympathetic drive is high (ACC/AHA 2017+2025)

Setting playbook (outpatient) — Bridge encounter at 1 wk post-discharge (the STRONG-HF analog anchor visit) — confirm euvolemia + BP at target maintained, complete unfinished secondary cause workup, set the biweekly titration trajectory before formal handoff to chronic HTN engine cardio.htn.core.v1
4. continue 4-tier oral regimen at week-1 dose Amlodipine 5–10 + lisinopril 10–40 + chlorthalidone 12.5–25 PO daily — Stable BP at d/c (Maintain ACC/AHA 2017+2025 ladder; tune by home BP trend)
5. first up-titration of ARB/ACEi if BP >130/80 Lisinopril 10 → 20 → 40 mg daily (or losartan 50 → 100 mg) PO daily — BP not at <130/80 + K <5.0 + eGFR stable (STRONG-HF analog intensive titration; SPRINT (PMID 26551272) <130 SBP anchor)
6. add MRA if resistant phenotype Spironolactone 12.5 → 25 mg daily PO daily — Resistant + K <5 + eGFR ≥30 (PATHWAY-2 4th-line option (ACC/AHA 2017+2025))

Non-pharmacologic actions:
- Reinforce BID home BP log + DASH diet + sodium <2 g/d (ACC/AHA 2025)
- Confirm next visit booked at week 3 (biweekly through week 6 per STRONG-HF analog cadence)
- Confirm secondary cause specialty referrals booked (endo / vascular / sleep / nephrology) (ACC/AHA 2025)
- Cardiac rehab kick-off if not started post-MI (ACC/AHA 2022 HF Class I)

AVOID / contraindication checks:
- Nitroprusside_cyanide_avoid_AKI (ACC/AHA 2017)
- Hydralazine_predictable_drop_avoid (ACOG 2019)
- ACEi_ARB_avoid_pregnancy_except_SRC (ACC/AHA 2017; ACOG 2019)
- Cocaine_avoid_pure_BB_monotherapy (ACC/AHA 2017; Vaughan JAMA 2000)
- Dissection_BB_FIRST_then_vasodilator (ACC/AHA 2022 Aortic)

Monitoring

Regimen monitoring:
- arterial line q5min BP (ACC/AHA 2017)
- continuous ECG (ESC/ESH 2023)
- neuro exam q15min first hour (Vaughan JAMA 2000)
- serial creatinine q4-6h (ACC/AHA 2017)
- serial troponin if chest pain (ACC/AHA 2017)
- fundus exam initial and 24h (ESC/ESH 2023)
- UOP hourly (ACC/AHA 2017)

Setting (outpatient) monitoring:
- Home BP log review weekly via patient portal or call (ACC/AHA 2025)
- BMP at next visit (week 3) — earlier if eGFR borderline or K trending up
- NT-proBNP if HF symptoms recur (ACC/AHA 2022 HF)

Monitoring phase: Arterial line + q5min BP for emergency; q15min for urgency; serial neuro + perfusion + Cr + troponin (ESC/ESH 2023; ACC/AHA 2017)

Disposition

Current setting: outpatient — Bridge encounter at 1 wk post-discharge (the STRONG-HF analog anchor visit) — confirm euvolemia + BP at target maintained, complete unfinished secondary cause workup, set the biweekly titration trajectory before formal handoff to chronic HTN engine cardio.htn.core.v1

Disposition criteria:
- Confirm continuation in transition setting (next biweekly visit week 3) — formal handoff to cardio.htn.core.v1 occurs when BP <130/80 maintained ≥4 wk on max-tolerated regimen + secondary cause workup complete (per STRONG-HF analog post-trial cadence)

Escalation triggers (move to higher acuity):
- BP rebound to ≥180/120 → return to ED (ACC/AHA 2017+2025)
- New end-organ symptoms → return to ED + IV pathway
- K rising >5.5 on MRA → hold MRA first; consider K binder (ACC/AHA 2025 IIa)
- Cr rise >30% from discharge baseline → reduce diuretic; reassess volume
- Symptomatic hypotension after up-titration → hold next dose, recheck in 1 wk

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Tearing pain + inter-arm gradient + mediastinal widening (ACC/AHA 2022 Aortic)
- [LIFE_THREATENING] CT head shows ICH with SBP >140 (Anderson NEJM 2023; AHA/ASA 2022)
- [LIFE_THREATENING] Pregnancy + BP ≥160/110 + severe features — HA, vision, RUQ, AMS, low platelets, AKI, transaminitis (ACOG 2019)

Citations

- 2025 ACC/AHA HTN Guideline (PMID 40811497) + ESC/ESH 2024 HTN (McEvoy, PMID 39210715) + AHA/ASA 2022 ICH + ACC/AHA 2022 Aortic (Isselbacher, PMID 36322642) + ACOG Practice Bulletin 222 (2019/2022) + ACEP 2024 Asymptomatic Severe HTN Policy [PMID:40811497](https://pubmed.ncbi.nlm.nih.gov/40811497/)
- Cited evidence (PMID 39210715) [PMID:39210715](https://pubmed.ncbi.nlm.nih.gov/39210715/)
- Cited evidence (PMID 36322642) [PMID:36322642](https://pubmed.ncbi.nlm.nih.gov/36322642/)
- Cited evidence (PMID 17709637) [PMID:17709637](https://pubmed.ncbi.nlm.nih.gov/17709637/)
- Cited evidence (PMID 23922146) [PMID:23922146](https://pubmed.ncbi.nlm.nih.gov/23922146/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2025 ACC/AHA HTN Guideline (PMID 40811497) + ESC/ESH 2024 HTN (McEvoy, PMID 39210715) + AHA/ASA 2022 ICH + ACC/AHA 2022 Aortic (Isselbacher, PMID 36322642) + ACOG Practice Bulletin 222 (2019/2022) + ACEP 2024 Asymptomatic Severe HTN Policy — PMID:40811497
  • Cited evidence (PMID 39210715) — PMID:39210715
  • Cited evidence (PMID 36322642) — PMID:36322642
  • Cited evidence (PMID 17709637) — PMID:17709637
  • Cited evidence (PMID 23922146) — PMID:23922146