Summary of the 2008 EMCREG hypertension guidelines

Recommendations Process.pdf (page 1 of 2)


This post has been superseded by this one.


All BP values are linked with or as in SBP of 220 or a DBP of 120.

No end organ damage

Administering antihypertensive therapy in the ED for the purpose of acutely lowering blood pressure in patients without end-organ damage is discouraged.

Commence oral antihypertensive therapy if BP > 200/120. Consider commencing oral therapy if BP > 180/110.

A basic metabolic panel is recommended before starting a patient on antihypertensives. Avoid ACE inhibitors in woman of childbearing potential. All hypertensive patients require follow-up.

Acute Ischemic Stroke not being treated with thrombolysis

Unless concomitant condition requiring BP control, do not treat until over 220/120. Keep above 140/90. Use labetalol or nicardipine.

Spontaneous Intracerebral Hemorrhage not SAH

If signs of high ICP, keep MAP below 130 or SBP below 180. If no signs of high ICP, keep MAP below 110 or SBP below 160. Use labetalol, nicardipine, or esmolol.

Subarachnoid Hemorrhage

Keep SBP below 160 until clipped or vasospasm occurs. Use labetalol, nicardipine, or esmolol. Oral nimodipine is used for vasospasm prophylaxis, not treatment of hypertension, though it may lower blood pressure.

Traumatic Brain Injury

Do not treat hypertension. Keep CPP between 50 and 70, but do not use vasopressors.

Acute Coronary Syndrome

Reduce by 20-30% if > 160/100 with IV/SL nitro or beta blocker.

Avoid thrombolytics if > 185/110

Heart Failure / Pulmonary Edema

Treat hypertensive and normotensive pulmonary edema patients with IV/SL nitro or ACE inhibitor.

Hypertensive encephalopathy

Reduce MAP by 25% over eight hours with labetalol, nicardipine, or esmolol.

Aortic Dissection

Keep SBP below 110, unless symptomatic hypotension, using morphine, beta blocker (metoprolol, esmolol, labetolol), followed by vasodilator (nicardipine, nitroprusside). Calcium channel blocker (verapamil, diltiazem) may be used instead of beta blocker. Avoid beta blocker if aortic regurgitation or cardiac tamponade. Remember to measure BP in both arms. [My note: target heart rate is 60-80]

Preeclampsia or Eclampsia

Keep SBP < 160 and DBP < 110 if prepartum or intrapartum. Use 150/110 if postpartum or platelets < 100,000. Use IV labetalol or hydralazine or oral nifedipine. ACE inhibitors and esmolol are contraindicated. Treatment for eclampsia should also include magnesium, 6 g over 20 minutes, then 2 g per hour.


Asymptomatic hypertension does not require treatment. If treatment is required, benzodiazepines are first-line therapy. If cocaine-related ACS, add nitroglycerine or IV phentolamine. Avoid beta blockers, including labetalol.