Hypertensive crisis: symptoms, when it is an emergency and how it is treated

The NHS says high blood pressure does not usually cause symptoms and many people do not know they have it. Rarely, it can cause headaches, blurred vision or chest pain. The NHS advises getting help from NHS 111 if you often have headaches or blurred vision, have chest pain that comes and goes, or have other symptoms you are worried could be caused by high blood pressure.

NICE lists the life-threatening symptoms that, together with a reading of 180/120 or higher, call for same-day specialist assessment: new-onset confusion, chest pain, signs of heart failure and acute kidney injury. Other presentations that suggest an emergency in practice include sudden severe headache, weakness or speech difficulty, and breathlessness, all of which need 999.

NICE says that if a person has severe hypertension but no symptoms or signs needing same-day referral, tests for target organ damage should be done as soon as possible. If damage is found, drug treatment can be considered immediately without waiting for ambulatory or home monitoring. If no damage is found, the diagnosis is confirmed by repeating the clinic reading within 7 days or by monitoring with ABPM or home readings, with clinical review within 7 days. Same-day specialist referral is also advised for suspected phaeochromocytoma, which is a rare hormone-producing tumour.

Blood pressure is written as two numbers. The NHS says a reading of 140/90 or higher in a clinic, or 135/85 or higher at home, is usually considered high blood pressure. NICE guideline NG136 describes severe hypertension as a clinic systolic pressure of 180 mmHg or higher, or a clinic diastolic of 120 mmHg or higher. That is the level most often meant by the term hypertensive crisis.

The crucial distinction is between severe hypertension on its own and severe hypertension with signs of acute organ damage. NICE defines target organ damage as damage to organs such as the heart, brain, kidneys and eyes, for example left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy or raised urine protein.

NICE defines accelerated hypertension as a severe increase in blood pressure to 180/120 mmHg or higher, often over 220/120, with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve). It is usually associated with new or progressive target organ damage and is also known as malignant hypertension. Looking at the back of the eye is therefore part of assessing anyone with a very high reading, which is why opticians and GPs may ask about blurred vision.

The NHS says call 999 if you get sudden pain or discomfort in the chest that does not go away, which can feel like squeezing, pressure, burning or indigestion; pain that spreads to the left or right arm, neck, jaw, stomach or back; or chest pain with sweating, sickness, light-headedness or breathlessness. These could signal a heart attack. Do not drive yourself to A&E; the 999 call handler will advise.

Sudden weakness of the face, arm or leg, slurred speech or a sudden severe headache are stroke or bleed warning signs and also need 999.

A very high reading with symptoms is handled as an emergency through 999, NHS 111 or A&E, followed by same-day specialist assessment in hospital. A very high reading with no symptoms is usually handled by a GP, who arranges tests for organ damage and a recheck within 7 days, as NICE advises.

Private cardiology or hypertension clinics can arrange quicker tests and follow-up, but they are not a substitute for emergency care when symptoms are present.

The NHS says that if blood pressure is too high it puts strain on blood vessels, heart and other organs, and untreated it raises the risk of heart disease, heart attacks, strokes, heart failure, kidney disease and vascular dementia. Lowering it even a small amount helps reduce risk. Lifestyle steps include a healthy diet, at least 150 minutes of exercise a week, losing weight if overweight, less salt, no more than 14 alcohol units a week on a regular basis, less caffeine and not smoking. A GP usually prescribes medicine if blood pressure is very high or you are at higher risk of problems linked to it, and you may need more than one medicine.