Severe BP or hypertensive emergency?

Severe hypertension (2025 AHA/ACC): BP above 180/120 mm Hg — systolic above 180 or diastolic above 120. 180/120 itself is not severe. The 2025 guideline retires the term “hypertensive urgency.”

Hypertensive emergency: severe hypertension with evidence of acute target-organ damage. Organ damage can occur below the threshold (2024 AHA statement). The tool then shows the condition’s own target, and IV agents only when BP is above that target.

Asymptomatic high inpatient BP (the 2024 AHA statement calls it “elevated”): 130/80 mm Hg or higher without new or worsening organ damage. In 2025 guideline terms that is stage 1–2 hypertension (up to 180/120) or severe hypertension (above 180/120); “elevated” in the 2025 guideline means 120–129 with diastolic under 80. The tool says “hypertension range, not severe” or “severe hypertension.”

Pregnancy and up to 6 weeks postpartum (2025 guideline, ACOG): severe range is systolic 160 or higher or diastolic 110 or higher, confirmed within 15 minutes. It is treated without waiting for organ damage. At 20 weeks or more, or after delivery, 140–159/90–109 starts serial BP, a symptom check and preeclampsia labs.

With no compelling condition, the 2025 guideline (COR 1, LOE C-LD) lowers systolic BP by no more than 25% in the first hour, then to under 160/100 within the next 2–6 hours if stable, then cautiously to 130–140 over the next 24–48 hours. The tool rounds the first-hour floor up so the fall never exceeds 25%.

For aortic dissection the target is systolic under 120 and heart rate 60–80, so the tool shows the fall that target requires. For ICH and ischemic stroke it uses the stroke guidelines instead, because the 2025 recommendation excludes stroke and ICH.

Each condition’s own rule decides whether to lower BP and to what. The generic 180/120 emergency rule never overrides it. Precedence: aortic dissection, then ICH, then severe-range BP in pregnancy or postpartum, then ischemic stroke. The first of these whose BP is above its own target sets the one working target shown at the top. Agents are marked preferred only while BP is above that target.

Ischemic stroke with ACS or heart failure, in any reperfusion state, defers to the comorbid condition (2026 stroke guideline §4.3 Rec 2, COR 1 · C-EO). Its supporting text gives an individualized initial reduction of about 15%. The tool applies that only above SBP 140, never goes below 140, and keeps the reperfusion ceilings. Only when no compelling condition is ticked do catecholamine excess, the staged 25% rule and the 2024 AHA statement apply.

Targets conflict. Where two conditions have conflicting guideline targets and no guideline reconciles them (aortic dissection with ICH), the tool computes no working target. It lists each condition’s own target with its source and marks preferred only agents that every ticked condition allows. In dissection, rate control comes first, so no vasodilator is marked preferred.

Every “Preferred” line and every agent card, ACOG cards included, comes from one allowed-agent check that sees all the ticked conditions.

Doses follow the US label where one exists. Values that appear only in the 2025 guideline’s Table 26 are marked 2025 Table 26; not re-verified against the label. Fenoldopam has no current US label, so all its values come from the guideline.

Pheochromocytoma. In the 2025 guideline, Figure 9 shows systolic under 140 in the first hour. The supportive text says pheochromocytoma should not be treated as a compelling reason for that target. The tool shows both and does not pick one. The esmolol label says to start it only after an alpha-blocker. The labetalol label reports paradoxical hypertension in pheochromocytoma.

Dissection timing. The 2025 recommendation says under 120 within the first hour; its Table 27 says 120 or lower within 20 minutes. The 2022 aortic guideline adds heart rate 60–80.

ICH. The 2022 ICH guideline targets 140 and keeps systolic between 130 and 150 (COR 2b). The newer 2025 BP guideline suggests 130 to under 140 for at least 7 days and stopping drugs below 130 (COR 2a). Both say not to go below 130.

Severe ischemic stroke BP without reperfusion. For 220/120 or higher, the 2026 stroke guideline calls the benefit of treatment uncertain (COR 2b). Its supporting text suggests an individualized first fall of 15%.

Pregnancy target. The 2025 guideline says to get under 160/110 within 30–60 minutes. The ACOG 2023 algorithm aims for 130–150/80–100.

Labetalol infusion in pregnancy. ACOG PB 222 gives 1–2 mg/min. The copy of the ACOG table in the 2025 guideline gives 1–3 mg/min. The tool shows the ACOG value.

Not given by the guideline. The 2025 guideline gives no numeric target for AKI and does not address thrombotic microangiopathy. The tool shows the 2024 AHA scientific statement’s suggestion and labels it as such.

Inpatient hypertension · BP measurement · Aortic dissection tool · Stroke · Stroke thrombolysis tool · ACS · AKI · Drip calculator