Last year, the American College of Cardiology (ACC)/American Heart Association (AHA) and several other organizations released a joint clinical practice guideline that addressed a wide set of issues related to prevention, detection, evaluation, and management of asymptomatic hypertension in adults, including redefining the concept of “hypertensive urgency.”¹

“In the past we used this term ‘hypertensive urgency’ and primary care doctors, if they saw someone with a [blood pressure] BP of 180/120 or higher, would reflexively send them to the emergency department (ED),” said Joseph Miller, MD, MS, an emergency physician at Henry Ford Health in Detroit.

In fact, an older study showed that from 2006 to 2015, hypertension was the primary complaint in 0.6 percent of all ED visits—more than 6.2 million visits—whether referred from a physician or through self-referral.²

What was called hypertensive urgency is now referred to as severe hypertension and is defined as a BP >180/120 mm Hg without evidence of acute target organ damage.

“The ACC/AHA guideline has gotten rid of that term and encouraged that it be wiped from the medical lexicon,” Dr. Miller said. “And, fortunately, the number of referrals to the ED already appears to be dropping and will hopefully continue to drop.”

That is because the guideline recommends that these patients should not receive aggressive BP lowering in the short term or be given parenteral antihypertensive drug therapy. Instead, it calls for a reinstitution or intensification of oral antihypertensive medications, ideally in an outpatient setting.¹

However, according to Curt Dill, MD, associate professor of emergency medicine at Weill Cornell Medical College in New York, “there is often a disconnect between what should be done ideally, and what can be done in the real world.”

Complexities

Despite this update from the ACC/AHA, practice patterns for addressing asymptomatic hypertension vary in emergency medicine. In its 2013 Clinical Policy, ACEP did not recommend routine ED medical interventions for these patients, unless the patient had poor follow-up or was considered high risk.³ However, in an update published in 2025, ACEP amended this recommendation based on a more recent study that showed that initiating antihypertensive medications in the ED lowered BP in the short term without any increase in adverse events.^4,5 The guideline gives a Level C recommendation to consider the initiation of outpatient antihypertensive medications, with a referral for outpatient follow-up.

“The [ACC/AHA] guidelines are good, but in practice clinicians have to assess what kind of access each individual patient has to good general primary care—that is also a key driver,” Dr. Dill said. “Working in an urban environment, for example, most of the patients we see are not going to call their primary care doctor to see them in a week for a resting BP.”