Hypertensive Emergencies in Diverse Settings: Diagnostic Strategies, Therapeutic Approaches, and Outcome Disparities

This narrative review explores hypertensive emergencies, which account for 0.3%-0.5% of emergency department (ED) visits. We selected studies published between 2020 and 2025 through a focused search of PubMed and Google Scholar using keywords like ‘hypertensive emergency’, ‘pregnancy-induced hypertension’, and ‘IV antihypertensives’. Neuroimaging, ECG, and cardiac biomarkers are key diagnostic tools. IV agents such as labetalol, nicardipine, and hydralazine remain essential for rapid BP control. Trials in pregnancy settings highlight nicardipine’s advantage in respiratory outcomes and nifedipine’s BP-lowering efficacy. Adherence-focused interventions and pharmacogenetic studies underline challenges in chronic BP control. While mHealth has promise, clinical disparities persist. This review emphasizes integrated, evidence-informed approaches tailored to diverse clinical settings. In pregnancy, an open-label randomized trial found that nicardipine was associated with fewer cases of respiratory distress syndrome (12.5%) compared to labetalol (42.9%, p=0.04), although differences in overall neonatal outcomes were not statistically significant (p=0.12). Another trial showed that nifedipine was most effective for single-dose BP reduction. The Norwegian therapeutic drug monitoring (TDM) trial showed no significant BP difference between groups at 3 or 6 months, though adherence improved in both arms. A sub-study on amlodipine pharmacokinetics demonstrated that lower controlled dose ratios (CDRs) were associated with uncontrolled hypertension (HTN) (5.6 vs. 6.3 nmol/L/mg, p=0.014). The Reach Out trial in a U.S. safety-net ED showed a 6.6 mmHg systolic BP reduction at 12 months. However, no mHealth component significantly affected BP, and disparities in outcomes persisted among Black participants.