Cardiac emergencies and arrhythmias

Hypertensive emergencies

Reviewed Nov 2026·2 references
New· views rounded down, updated weekly

Hypertensive emergency means severe BP elevation with acute organ damage. Lower BP with titratable IV drugs to a target and timeline set by the organ involved; avoid precipitous falls except in aortic dissection, pulmonary oedema and eclampsia.

At the bedside

Timed steps
  1. 1

    Confirm organ damage

    0 min

    Encephalopathy, stroke/ICH, ACS, pulmonary oedema, aortic dissection, AKI, TMA, retinopathy (malignant), eclampsia. No organ damage = urgency: oral therapy, not IV.

  2. 2

    Pick target by organ

    0-60 min

    See table. General: MAP fall ≤ 20-25% in the first hours.

  3. 3

    Pick drug

    0-60 min

    Labetalol (most), nicardipine (stroke, encephalopathy, AKI), GTN (ACS, pulmonary oedema), esmolol + vasodilator (dissection), labetalol or nicardipine plus magnesium (eclampsia).

  4. 4

    Arterial line

    Monitor

    BP every 5-15 min during titration; neurological checks.

  5. 5

    Find cause

    Next

    Non-adherence, renal artery stenosis, phaeochromocytoma, drugs (cocaine, amphetamine, MAOI), pre-eclampsia, renal disease.

General first-line

Labetalol

IV
Dose
20 mg over 2 min, repeat 20-80 mg every 10 min (max 300 mg) or infusion 1-2 mg/min
Preparation
Undiluted 5 mg/mL
Worked example
1 mg/min = 60 mg/h ÷ 5 = 12 mL/h
Open infusion calculator

Stroke, encephalopathy, AKI

Nicardipine

IV infusion
Dose
5 mg/h, +2.5 mg/h every 5-15 min, max 15 mg/h

Aortic dissection (with vasodilator)

Esmolol

IV
Dose
500 mcg/kg bolus, then 50-300 mcg/kg/min
Target
HR < 60, SBP < 120 mmHg

BP targets by clinical presentation (ESC 2019 position)

PresentationTimelineTargetFirst-line
Malignant hypertension ± TMA/AKISeveral hoursMAP −20-25%Labetalol, nicardipine
Hypertensive encephalopathyImmediateMAP −20-25%Labetalol, nicardipine
Acute ischaemic stroke, BP > 220/120 (no lysis)1 hMAP −15%Labetalol, nicardipine
Ischaemic stroke for thrombolysis, BP > 185/1101 h< 180/105Labetalol, nicardipine
Acute ICH, SBP > 180ImmediateSBP 130-180Labetalol, nicardipine
ACSImmediateSBP < 140GTN, labetalol
Acute cardiogenic pulmonary oedemaImmediateSBP < 140GTN, nitroprusside (+ loop diuretic)
Acute aortic dissectionImmediateSBP < 120 and HR < 60Esmolol + GTN or nitroprusside
Eclampsia / severe pre-eclampsiaImmediateSBP < 160 and DBP < 105Labetalol or nicardipine + magnesium
Red flag · call your senior now
Neurological decline during BP lowering: you may be lowering too fast.
Red flag
Severe hypertension with tachycardia, sweating, headache: phaeochromocytoma or sympathomimetic toxicity (no beta-blocker first).
Pitfall
Sublingual nifedipine (uncontrolled falls, stroke, MI).
Pitfall
Treating asymptomatic severe hypertension with IV drugs.
Pearl
In stroke and ICH, see module 20 for current targets (INTERACT trials).

Calculators for this topic

Mean arterial pressure

(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).

Infusion rate from a fixed hourly or per-minute dose

Pump rate for non-weight-based infusions such as vasopressin (U/min), labetalol (mg/min) or amiodarone (mg/h).

References

  1. 1

    van den Born BH, Lip GYH, Brguljan-Hitij J, et al. ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmacother. 2019;5(1):37-46

  2. 2

    McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912-4018

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Bradycardia, heart block and temporary pacing

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.