What is the clinical evidence from this study?

Study design: Systematic Review. Population: Hypertensive crises (emergencies and urgencies). Intervention: Pharmacological antihypertensive strategies (continuous intravenous infusion, IV bolus, oral medications) vs. Alternative treatments, standard care, or no treatment. Primary outcome: Blood pressure control, major adverse events, and mortality.

What question did this study set out to answer?

This review synthesizes evidence on pharmacological strategies for managing hypertensive crises to guide clinical practice.

March 25, 2026Open Access

Management Strategies for Hypertensive Crises: A Systematic Review of Evidence-Based Approaches

Key Result

Continuous intravenous infusion achieved the fastest blood pressure reduction in hypertensive crises, while emergency department antihypertensive therapy reduced 5-year mortality by 22%.

Key Points

This review synthesizes evidence on pharmacological strategies for managing hypertensive crises to guide clinical practice.
Systematic review following PRISMA guidelines.
Comprehensive search across multiple databases for studies published from 2020 to 2025.
Inclusion of studies evaluating pharmacological interventions in adults with hypertensive crises.
Risk of bias assessed using the Newcastle-Ottawa Scale.
Narrative synthesis conducted due to clinical and methodological heterogeneity.
Continuous intravenous infusion achieved the fastest blood pressure reduction.
Intravenous bolus was linked to shorter ICU stays.
No significant difference in time to blood pressure control was noted between treated and untreated patients.
Acute kidney injury occurred in 20-30% of hypertensive emergency patients with heart failure.
Overall mortality among ICU patients was 8%, higher with acute coronary syndrome.

Study Design

Type

Systematic Review

Structured PICO

Do pharmacological management strategies improve clinical outcomes and blood pressure control in adult patients with hypertensive crises?

Population

Adult patients with hypertensive crises (emergencies and urgencies)

Intervention

Pharmacological management strategies (various antihypertensive agents via continuous infusion, bolus, or oral routes)

Comparator

Alternative treatments, standard care, different dosing strategies, or no treatment

Outcome

Blood pressure control, major adverse events, and mortality

Pharmacological management of hypertensive crises should be tailored to the clinical context, with continuous infusions providing rapid control and bolus dosing minimizing ICU stay.

Limitations

Small number of included studies (n=6)
Considerable heterogeneity in study designs, populations, interventions, and outcome measures
Exclusion of non-English-language publications
Predominance of observational studies susceptible to confounding and bias
Potential publication bias
Inconsistent reporting of adverse events
Limited applicability to low-resource settings

Abstract

Hypertensive crises, encompassing emergencies and urgencies, are acute, severe blood pressure elevations associated with significant morbidity and mortality. Despite available guidelines, variability in clinical practice persists. This systematic review aims to synthesise evidence on pharmacological management strategies for hypertensive crises, focusing on efficacy, safety, and setting-specific considerations. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a comprehensive search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library was conducted for studies published between January 2020 and December 2025. Studies evaluating pharmacological interventions in adult patients with hypertensive crises were included. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). A narrative synthesis was performed due to clinical and methodological heterogeneity. The search yielded 629 records, of which six studies met the inclusion criteria, with two randomised controlled trials, two retrospective cohort studies, and two cross-sectional studies conducted across India, Taiwan, the United States, Ethiopia, the Netherlands, and Europe. All studies demonstrated low risk of bias, with NOS scores ranging from 7 to 9 stars. Continuous intravenous infusion achieved the fastest blood pressure reduction, while intravenous bolus alone was associated with the shortest intensive care unit (ICU) stay. One study found no significant difference in time to blood pressure control between treated and untreated emergency department patients, but observed reduced three-year and five-year mortality in treated patients. Overall mortality among ICU patients was 8%, with higher rates in those presenting with acute coronary syndrome. Both phenoxybenzamine and doxazosin were effective in preventing intraoperative haemodynamic instability during pheochromocytoma resection, with zero 30-day mortality. Acute kidney injury occurred in 20-30% of patients with hypertensive emergencies complicated by heart failure. Guidelines recommended against routine early intensive blood pressure lowering in acute ischaemic stroke due to the absence of proven mortality benefit and potential harm. Factors associated with better outcomes included polypharmacy approaches, formal end-organ damage evaluation, and absence of target organ damage. Multiple pharmacological strategies are effective in hypertensive crises, with choice guided by clinical context and target organ damage. Continuous infusion offers the fastest reduction, and bolus strategies reduce ICU utilisation. Target organ damage, especially acute coronary syndrome, predicts worse outcomes. Emergency department intervention confers long-term mortality benefits. Standardised definitions and larger trials are needed, particularly in resource-limited settings.

Bookmark

View Full Paper