Inpatient hypertension.
Treat the patient, not the number. One question decides everything: new organ damage, or just a number? A 5-step bedside algorithm for asymptomatic inpatient BP, plus the IV dosing table for true hypertensive emergency.
Reviewed October 2026 · verify against current guidelines
Doses on the slides are superseded — use the corrected table below. Corrected October 2026: this page now follows the 2025 AHA/ACC high blood pressure guideline (and the 2026 stroke, 2022 ICH, 2022 aortic and ACOG guidance where they apply), with doses checked against US labels. The slides were posted before these corrections. Work a case in the BP emergency tool.
Diagnosis & Workup
Step 1: Confirm the reading.
Measure correctly
Right cuff size, arm supported, patient seated and rested. Repeat before acting.
Measurement artifact to exclude
| Technique | Wrong cuff size, arm unsupported, talking, legs crossed. |
|---|---|
| Context | White coat, no rest before reading, recent activity or caffeine. |
A single high reading is not a diagnosis. Repeat before you treat.
Diagnosis & Workup
Step 2: Emergency or not?
Classification (2025 AHA/ACC · AHA 2024)
| Stage 1–2 hypertension | SBP 130–180 or DBP 80–120 (at or below 180/120), with no new or worsening organ damage. 2025 AHA/ACC stages 1–2; the AHA 2024 statement calls this asymptomatic elevated inpatient BP. (2025 “elevated” means 120–129 with DBP under 80.) |
|---|---|
| Severe hypertension | SBP above 180 or DBP above 120, with no new or worsening organ damage. Formerly “urgency” (2025 AHA/ACC). |
| Emergency | Severe BP plus new or worsening organ damage (2025 AHA/ACC). Damage can occur below 180/120 (AHA 2024). |
Organ damage = emergency (BARKH + heme + pregnancy)
| Brain | Encephalopathy, PRES, ischemic stroke, intracranial hemorrhage. |
|---|---|
| Arteries | Acute aortic syndrome: dissection, penetrating ulcer. |
| Pregnancy | Preeclampsia with severe features, eclampsia, HELLP. |
| Retina | Retinal hemorrhage, papilledema. |
| Kidney | Acute kidney injury. |
| Heart | Acute coronary syndrome, acute decompensated heart failure / pulmonary edema. |
| Heme | Microangiopathic hemolytic anemia with thrombocytopenia (thrombotic microangiopathy), per the AHA 2024 statement. |
Look before you label — history: known hypertension, home drugs, adherence, outpatient readings. Exam: compare pulses in both arms, heart, lungs, fundi. Tests: basic metabolic panel, CBC, chest X-ray, 12-lead ECG, volume status and orthostasis risk (AHA 2024 statement). Troponin and urinalysis help confirm cardiac or kidney injury. Headache, anxiety or epistaxis alone are not organ damage.
SBP systolic BPDBP diastolic BPPRES posterior reversible encephalopathy syndrome
Acute Management
Step 3: Asymptomatic path.
Less is more
Severe BP elevation without organ damage still does not need acute treatment.
Identify and treat triggers
| Symptoms | Pain, anxiety, acute stress, sleep deprivation, the acute illness itself. Check volume status. |
|---|---|
| Medications | Home meds not restarted, NSAIDs, corticosteroids, stimulants, excess IV fluids, cocaine or methamphetamine. |
Then
- Treat the cause: analgesia, hold offending drugs, correct volume.
- Restart home antihypertensives first.
- BP above 180/120 in a noncardiac admission without organ damage: no extra IV or oral doses to lower BP acutely (2025 AHA/ACC, Class 3: Harm). Use standing, not as-needed, medicines with frequent monitoring (2025 AHA/ACC supportive text).
- Document and arrange outpatient follow-up.
Why not treat the number — 2025 AHA/ACC: in observational studies, extra IV or oral doses in noncardiac inpatients carried “increased risk of in-hospital mortality, AKI, and prolonged hospital stay.” Rastogi 2021: treated patients had more AKI (10.3% vs 7.9%) and myocardial injury (1.2% vs 0.6%). Anderson 2023 (age 65 and older): more of the composite outcome (8.7% vs 6.9%) — AKI, troponin and BNP rise and ICU transfer, but not stroke or death.
NSAID nonsteroidal anti-inflammatory drug
Acute Management
Step 4: Emergency targets.
Lower in stages (2025 AHA/ACC; no compelling condition)
| First hour | Reduce SBP by no more than 25%. Do not normalize BP. |
|---|---|
| 2–6 hours | Then to under 160/100 mm Hg if stable. |
| 24–48 h | Then cautiously to 130–140 mm Hg. |
| Not for | Aortic dissection, acute ischemic stroke, ICH, pregnancy or postpartum. These have their own targets (below). |
Also
- ICU with continuous BP monitoring.
- Still treat pain, agitation, volume, drugs.
Own targets —
Aortic dissection: SBP under 120 within the first hour, then heart rate 60–80 as the ongoing target; IV beta-blocker first (2022 ACC/AHA; 2025 AHA/ACC).
Pheochromocytoma or stimulant crisis: no agreed numeric target. Lower promptly with phentolamine, clevidipine or nicardipine; no beta-blocker until an alpha-blocker is running (2025 Table 27; esmolol label).
Ischemic stroke: under 185/110 before thrombolysis, then under 180/105 for 24 h. Thrombectomy planned, no thrombolysis: 185/110 or lower before the procedure (2a). No reperfusion: below 220/120, starting BP drugs in the first 48–72 h does not help (Class 3: No Benefit); at 220/120 or above the benefit is uncertain (2b). In mild to moderate stroke, pushing SBP under 140 after thrombolysis is not recommended (No Benefit). After successful thrombectomy keep 180/105 or lower (2a); without another indication, targeting SBP under 140 for the first 72 hours is harmful (Class 3: Harm). With a comorbid condition that needs BP treatment, such as ACS, heart failure, dissection or preeclampsia, treat BP early, with or without reperfusion (Class 1) (2026 AHA/ASA).
ICH, SBP 150–220: 130 to under 140 for at least 7 days, stopping BP drugs if SBP falls below 130 (2025 AHA/ACC, Class 2a); the 2022 AHA/ASA guideline aims for 140 and keeps 130–150 (2b). Lowering below 130 is potentially harmful. ICH, SBP above 220: a modest fall to 160–180, not below 130 (2025 AHA/ACC). Large ICH: no established target.
Pregnancy or up to 6 weeks postpartum: confirm severe range (160/110 or more) persisting 15 min or more, then treat within 30–60 min (ACOG). The 2025 AHA/ACC target is under 160/110; the ACOG algorithm then aims for 130–150/80–100.
Aortic dissection: SBP under 120 within the first hour, then heart rate 60–80 as the ongoing target; IV beta-blocker first (2022 ACC/AHA; 2025 AHA/ACC).
Pheochromocytoma or stimulant crisis: no agreed numeric target. Lower promptly with phentolamine, clevidipine or nicardipine; no beta-blocker until an alpha-blocker is running (2025 Table 27; esmolol label).
Ischemic stroke: under 185/110 before thrombolysis, then under 180/105 for 24 h. Thrombectomy planned, no thrombolysis: 185/110 or lower before the procedure (2a). No reperfusion: below 220/120, starting BP drugs in the first 48–72 h does not help (Class 3: No Benefit); at 220/120 or above the benefit is uncertain (2b). In mild to moderate stroke, pushing SBP under 140 after thrombolysis is not recommended (No Benefit). After successful thrombectomy keep 180/105 or lower (2a); without another indication, targeting SBP under 140 for the first 72 hours is harmful (Class 3: Harm). With a comorbid condition that needs BP treatment, such as ACS, heart failure, dissection or preeclampsia, treat BP early, with or without reperfusion (Class 1) (2026 AHA/ASA).
ICH, SBP 150–220: 130 to under 140 for at least 7 days, stopping BP drugs if SBP falls below 130 (2025 AHA/ACC, Class 2a); the 2022 AHA/ASA guideline aims for 140 and keeps 130–150 (2b). Lowering below 130 is potentially harmful. ICH, SBP above 220: a modest fall to 160–180, not below 130 (2025 AHA/ACC). Large ICH: no established target.
Pregnancy or up to 6 weeks postpartum: confirm severe range (160/110 or more) persisting 15 min or more, then treat within 30–60 min (ACOG). The 2025 AHA/ACC target is under 160/110; the ACOG algorithm then aims for 130–150/80–100.
Acute Management
IV agents & doses.
IV agents (US labels; 2025 AHA/ACC Tables 26–27; ACOG)
| Nicardipine | Dose: 5 mg/h; up 2.5 mg/h every 5–15 min (5 for rapid, 15 for gradual lowering); max 15 mg/h. Use for: ACS, AKI, stroke, ICH, preeclampsia, catecholamine excess. Avoid: Advanced aortic stenosis. |
|---|---|
| Clevidipine | Dose: 1–2 mg/h; double every 90 s at first, then less than double every 5–10 min near the goal. Most need 16 mg/h or less; experience up to 32 mg/h is limited; no more than 1,000 mL (an average of 21 mg/h) per 24 h; little experience beyond 72 h. Use for: Pulmonary edema, AKI, stroke, ICH, catecholamine excess. Avoid: Soy or egg allergy; defective lipid metabolism; severe aortic stenosis. |
| Labetalol | Dose: First 20 mg slow IV over 2 min (2025 table: 0.3–1.0 mg/kg, first dose max 20 mg), then 40–80 mg every 10 min; max 300 mg cumulative. Or infusion 2 mg/min (label), or 0.4–1.0 mg/kg/h up to 3 mg/kg/h (2025 table). Use for: Aortic dissection, ACS, stroke, ICH. Pregnancy: use the ACOG row. Avoid: Bronchial asthma; history of obstructive airway disease (label: should not be used); overt cardiac failure; heart block greater than first degree; cardiogenic shock; severe bradycardia; pulmonary edema; pheochromocytoma until alpha-blockade (paradoxical hypertension reported). |
| Esmolol | Dose: 500 mcg/kg over 1 min (or 1 mg/kg over 30 s), then 50 (or 150) mcg/kg/min; max 300 mcg/kg/min for hypertension. Use for: Aortic dissection, ACS (agent of choice), stroke, ICH. Avoid: Severe sinus bradycardia; heart block greater than first degree; sick sinus syndrome; decompensated HF; cardiogenic shock; IV verapamil close in time; pulmonary hypertension; pulmonary edema; pheochromocytoma until an alpha-blocker is running. Pregnancy: fetal bradycardia reported with use in the last trimester or labor (label). |
| Nitroglycerin | Dose: 5 mcg/min; up 5 mcg/min every 3–5 min; if no response at 20 mcg/min, steps of 10–20 mcg/min. The 2025 table caps it at 200 mcg/min; the label sets no maximum. Use for: ACS (agent of choice) and pulmonary edema only. Avoid: Volume depletion; raised intracranial pressure; pericardial tamponade; restrictive cardiomyopathy; constrictive pericarditis; PDE5 inhibitors; riociguat. |
| Nitroprusside | Dose: 0.3 mcg/kg/min; watch at least 5 min before each change; max 10 mcg/kg/min, as briefly as possible (cyanide buffering is exceeded in under 1 h at the maximum). Above 2 mcg/kg/min cyanide forms faster than it is cleared. eGFR under 30: mean rate under 3 mcg/kg/min; anuric: 1. Check thiocyanate above 7 mg/kg/day. Use for: Pulmonary edema; vasodilator after the beta-blocker in dissection. Avoid: Pregnancy, including preeclampsia before delivery (fetal cyanide; label); acute stroke or ICH unless no alternative (raises ICP); coarctation or AV shunting; PDE5 inhibitors or riociguat. |
| Hydralazine | Dose: 10 mg slow IV (first dose max 20 mg), repeat every 4–6 h (2025 table). Label: 20–40 mg IV or IM, repeated as necessary; average maximal fall at 10–80 min. Use for: Listed for ICH and stroke (2025 Table 27), but the label warns that lowering BP with raised ICP may worsen cerebral ischemia. Pregnancy: use the ACOG row. Avoid: Coronary artery disease; mitral valvular rheumatic heart disease (label); aortic dissection (reflex tachycardia). Poor first-line choice for most: unpredictable and long-acting. |
| Enalaprilat | Dose: 1.25 mg over 5 min every 6 h; 0.625 mg if on diuretics or CrCl 30 or less; up to 5 mg every 6 h was tolerated for up to 36 h; experience above 20 mg/day is inadequate. Onset about 15 min; peak up to 4 h. Use for: High-renin states (2025 table). Avoid: Pregnancy (boxed warning); prior ACE-inhibitor, hereditary or idiopathic angioedema; acute MI and bilateral RAS (2025 table); may worsen kidney injury in CKD. |
| Phentolamine | Dose: 5 mg IV (label); repeat every 10 min; max 50 mg/24 h (2025 table). Use for: Catecholamine excess: pheochromocytoma, MAOI interactions, cocaine, amphetamine, clonidine withdrawal. Avoid: MI or a history of MI; angina or coronary disease (label). |
| Fenoldopam | Dose: 0.1–0.3 mcg/kg/min; up 0.05–0.1 every 15 min; max 1.6 mcg/kg/min (2025 table; no current US label, limited availability). Use for: AKI. Avoid: Glaucoma; raised intracranial pressure; sulfite allergy. |
| Pregnancy or postpartum (ACOG) | Labetalol 10–20 mg IV, then 20–80 mg every 10–30 min, max 300 mg cumulative, or 1–2 mg/min infusion; avoid with asthma, preexisting myocardial disease, decompensated cardiac function, heart block or bradycardia (PB 222 Table 3). Hydralazine 5 mg IV or IM, then 5–10 mg IV every 20–40 min, max 20 mg cumulative, or 0.5–10 mg/h. Nifedipine immediate release 10–20 mg by mouth, repeat in 20 min if needed, then 10–20 mg every 2–6 h, max 180 mg/day. Magnesium sulfate 4–6 g IV over 20–30 min, then 1–2 g/h (ACOG PB 222). |
Match the drug to the organ. Titrate to target, not to normal.
ACS acute coronary syndromeCAD coronary artery diseaseHF heart failureRAS renal artery stenosisPDE5 phosphodiesterase-5 inhibitorAKI acute kidney injuryICH intracerebral hemorrhageICP intracranial pressureMI myocardial infarctionMAOI monoamine oxidase inhibitorCKD chronic kidney diseaseeGFR estimated glomerular filtration rateCrCl creatinine clearance
Pitfalls & Disposition
Step 5: Transitions of care.
Held doses drive spikes
NPO status, transfers, and med-rec gaps stop home meds. Restart them.
Rebound risk on withdrawal
| Clonidine | Abrupt stop causes rebound surge. Taper or restart. |
|---|---|
| Beta-blocker | Avoid abrupt cessation (2025 AHA/ACC drug table). Restart or taper. |
At discharge
- Resume the home regimen.
- Severe readings without organ damage: start, reinstitute or intensify oral therapy in a timely way, preferably as an outpatient (2025 AHA/ACC).
- Arrange close outpatient follow-up (2025 AHA/ACC Figure 9; AHA 2024 statement).
- Rastogi 2021: intensifying the regimen at discharge was not associated with better BP control over the next year.
- AHA 2024: BP that stays high both in and out of hospital may justify starting or intensifying oral drugs before discharge.
Chasing one high number with IV or new meds is the error, not the fix.
NPO nil per os / nothing by mouthmed-rec medication reconciliation
Sources
Verify against current guidelines and local protocol before acting.
- Bress AP et al. Management of Elevated Blood Pressure in the Acute Care Setting: AHA Scientific Statement. Hypertension 2024;81(8):e94–e106.
- Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. Circulation 2025;152(11):e114–e218 (also Hypertension 2025;82(10):e212–e316; J Am Coll Cardiol 2025;86(18):1567–1678). doi:10.1161/CIR.0000000000001356
- Rastogi R et al. Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. JAMA Intern Med 2021;181(3):345–352. doi:10.1001/jamainternmed.2020.7501
- Anderson TS et al. Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults. JAMA Intern Med 2023;183(7):715–723. doi:10.1001/jamainternmed.2023.1667
- Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation 2022;146(24):e334–e482. doi:10.1161/CIR.0000000000001106
- Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke 2026;57(8):e316–e436. doi:10.1161/STR.0000000000000513
- Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022;53(7):e282–e361. doi:10.1161/STR.0000000000000407
- American College of Obstetricians and Gynecologists. Gestational Hypertension and Preeclampsia. ACOG Practice Bulletin No. 222 (reaffirmed 2026). Obstet Gynecol 2020;135(6):e237–e260. doi:10.1097/AOG.0000000000003891
- American College of Obstetricians and Gynecologists. Acute Hypertension in Pregnancy and Postpartum Algorithm. 2023 (educational resource).
- US prescribing information (DailyMed): Brevibloc (esmolol); labetalol HCl injection; Nipride RTU (sodium nitroprusside); enalaprilat injection; hydralazine HCl injection; nitroglycerin in 5% dextrose; phentolamine mesylate for injection; Cleviprex (clevidipine); nicardipine HCl injection. Versions current October 2026.
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