A hypertensive emergency is the clinical-station scenario that tests whether you can separate a high number from a sick patient. NICE NG136 answers it with one threshold, two symptom lists and a same-day referral.

Key takeaways

  • NICE NG136, Hypertension in adults: diagnosis and management, was published on 28 August 2019 and last updated on 26 February 2026.
  • NICE defines stage 3 or severe hypertension as a clinic systolic blood pressure of 180 mmHg or higher, or a clinic diastolic of 120 mmHg or higher.
  • Recommendation 1.5.2 says to refer for specialist assessment carried out the same day if clinic blood pressure is 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema, which NICE calls accelerated hypertension, or with life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
  • Recommendation 1.5.3 adds a same-day referral for suspected phaeochromocytoma, giving labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis as examples.
  • Recommendation 1.5.1 says that severe hypertension without those features gets investigations for target organ damage as soon as possible, not a same-day referral.
  • NG136 does not state a target rate or percentage for lowering blood pressure in a hypertensive emergency, so the drug and the rate are specialist decisions made against local protocol.

How do you recognise a hypertensive emergency?

You recognise a hypertensive emergency by pairing the number with end-organ injury. NICE NG136 puts the number at a clinic blood pressure of 180/120 mmHg or higher, and then asks what else is present.

NICE defines accelerated hypertension as a severe increase in blood pressure to 180/120 mmHg or higher, and often over 220/120 mmHg, with signs of retinal haemorrhage and/or papilloedema, the swelling of the optic nerve.

The same definition notes that accelerated hypertension is usually associated with new or progressive target organ damage, and that it is also known as malignant hypertension.

  • Look at the fundi. Fundoscopy is the examination that turns severe hypertension into accelerated hypertension, and it is the one candidates forget to mention.
  • Ask about new onset confusion, chest pain, signs of heart failure and acute kidney injury, which are NICE's own examples of life-threatening symptoms.
  • Ask about labile or postural hypotension, headache, palpitations, pallor, abdominal pain and diaphoresis, which are NICE's examples of suspected phaeochromocytoma.
  • Check the blood pressure in both arms and examine for a radio-femoral delay, because aortic dissection is the diagnosis that changes the whole pathway.

What do you do in the first hour of a hypertensive emergency?

In the first hour of a suspected hypertensive emergency you confirm the pressure, look for end-organ damage and make the referral. NICE NG136 recommendation 1.5.2 makes that referral a same-day specialist assessment.

Assess A to E while you do it, because a hypertensive emergency presents as a complication rather than as a number: pulmonary oedema, a stroke, an acute coronary syndrome, an aortic dissection or an eclamptic seizure.

Recommendation 1.3.3 sets the investigations for target organ damage that NICE offers to everyone with hypertension, and these are what you order while arranging the referral.

  • A urine sample for albumin to creatinine ratio, and a reagent strip test for haematuria.
  • Bloods for HbA1c, electrolytes, creatinine, estimated glomerular filtration rate, total cholesterol and HDL cholesterol.
  • Examination of the fundi for hypertensive retinopathy.
  • A 12-lead electrocardiogram.

What is the named threshold, and what happens either side of it?

The named threshold in a hypertensive emergency is a clinic blood pressure of 180/120 mmHg. What NICE NG136 does next depends entirely on whether the features in recommendation 1.5.2 are present.

With retinal haemorrhage or papilloedema, or with life-threatening symptoms, recommendation 1.5.2 asks for specialist assessment carried out on the same day. With suspected phaeochromocytoma, recommendation 1.5.3 does the same.

Without them, recommendation 1.5.1 asks you to carry out investigations for target organ damage as soon as possible, and then splits again on the result.

  • If target organ damage is identified, consider starting antihypertensive drug treatment immediately, without waiting for the results of ambulatory or home blood pressure monitoring.
  • If no target organ damage is identified, confirm the diagnosis by repeating the clinic blood pressure measurement within 7 days, or by considering ambulatory or home monitoring with a clinical review within 7 days.

Being able to say what happens on the other side of the threshold is what a panel is testing. Severe hypertension is common; a hypertensive emergency is not, and the difference is examination findings.

What is the definitive management of a hypertensive emergency?

Definitive management of a hypertensive emergency is treatment of the end-organ complication under specialist supervision, usually with an intravenous agent titrated in a monitored setting.

Be honest about the limit of the guideline. NICE NG136 does not specify which intravenous agent to use or how fast to lower the pressure, so the correct answer is that this is a specialist decision against local protocol.

What you can say with confidence is that the agent depends on the complication, that treatment is titrated rather than given as a bolus, and that oral agents and sublingual nifedipine are not the answer to an emergency.

Say the reason out loud. An abrupt, uncontrolled fall in blood pressure in a patient whose cerebral autoregulation has shifted can cause ischaemic injury, which is why a monitored, titratable route is the safe one.

When do you escalate a hypertensive emergency, and to whom?

You escalate a hypertensive emergency the moment the fundi or the symptoms make it one, because NICE NG136 asks for specialist assessment carried out on the same day rather than at the next clinic.

  • Your own registrar and the medical consultant on call first, because the referral has to be made by someone who has seen the patient.
  • Critical care, where the patient needs a titratable intravenous agent and invasive monitoring.
  • The stroke team, cardiology or vascular surgery, according to the complication you have found.
  • Obstetrics immediately in a pregnant patient, because pre-eclampsia and eclampsia are a separate pathway.

How do you hand over a hypertensive emergency in one minute?

Hand over a hypertensive emergency with the pressure, the end-organ finding and the ask. The receiving team needs to know why this is an emergency rather than a high reading.

Use SBAR and put the fundoscopy finding in the assessment, because it is the single fact that justifies a same-day referral under NICE NG136.

A worked version, said aloud: this is a 52-year-old man with a blood pressure of 226/128 and bilateral papilloedema. His creatinine has risen and he is confused. I need a same-day specialist review and I think he needs a monitored bed.

What does the panel listen for in a hypertensive emergency answer?

The panel listens for whether you examine before you treat. In a hypertensive emergency, the fundi and the neurological examination decide the pathway, and a candidate who reaches straight for a drug has skipped the station.

  • That you use the 180/120 mmHg figure and know it is a clinic measurement.
  • That you name accelerated hypertension and can say what defines it.
  • That you distinguish a same-day referral from starting treatment and repeating the reading within 7 days.
  • That you say you would not lower the pressure quickly outside a monitored setting, and can say why.
  • That you ask whether the patient could be pregnant.

What are the common mistakes in a hypertensive emergency station?

The commonest mistake in a hypertensive emergency station is treating the number. A blood pressure of 200/115 with no symptoms, normal fundi and no target organ damage is not an emergency under NICE NG136.

  • Never mentioning fundoscopy, and so never being able to say the words accelerated hypertension.
  • Quoting a percentage reduction target as if NG136 stated one. It does not.
  • Giving a sublingual or oral agent to produce a fast fall, rather than arranging a titrated intravenous agent in a monitored setting.
  • Forgetting aortic dissection, where the management of blood pressure is different and urgent imaging comes first.
  • Missing pregnancy, where severe hypertension is an obstetric emergency on a different pathway.

How this comes up at the IMT interview

At the IMT interview, a hypertensive emergency appears in station 2, a clinical scenario of up to ten minutes on investigations, diagnosis and management, followed by a one-minute handover of the same patient.

It is a favourite because it turns easily. The panel can move a hypertensive emergency into a stroke, a dissection or a pregnancy and watch whether your structure survives the change.

internalmedicineinterview's bank of 361 IMT questions across 56 scenarios covers the clinical station with model answers and AI-marked spoken practice, for £97 to the end of the 2027 interview window.