title: Acute hypertension: a systematic review and appraisal of guidelines.
abstract: BACKGROUND
  Few clinical practice guidelines provide management recommendations for acute hypertensive episodes except in the context of specific conditions such as pregnancy and stroke.
  
  
  METHODS
  We performed a systematic search to identify guidelines addressing acute hypertension and appraised the guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) validated quality assessment tool. Two reviewers independently appraised and one extracted key recommendations. Literature on secondary hypertension, hypertension in pregnancy, preeclampsia/eclampsia, stroke, aortic dissection, and pheochromocytoma was excluded.
  
  
  RESULTS
  Three guidelines were identified, sponsored by the American College of Emergency Physicians (ACEP), the National Heart, Lung, and Blood Institute (NHLBI), and the European Society of Hypertension (ESH) in conjunction with the European Society of Cardiology (ESC). AGREE II yielded mean domain (%) and overall assessment scores (1-7) as follows: NHLBI: 73%, 5.5; ACEP: 67%, 5.5; and ESH/ESC: 56%, 4.5. In hypertensive emergencies, the NHLBI guideline recommends reducing mean arterial pressure by ≤25% for the first hour, and then to 160/100-110 mmHg by 2-6 hours with subsequent gradual normalization in 24-48 hours. The ESH/ESC has similar recommendations. The ACEP does not address guidelines for hypertensive emergency but focuses on whether screening for target organ damage or medical intervention in patients with asymptomatic elevated blood pressure in emergency departments reduces the rate of adverse outcomes, concluding that routine screening does not reduce adverse outcomes, but patients with poor follow-up may benefit from routine screening.
  
  
  CONCLUSIONS
  NHLBI and ESH/ESC guidelines are high quality and provide similar recommendations for management of asymptomatic acute hypertensive episodes and hypertensive emergencies. Additional research is needed to inform clinical practice guidelines for this common condition.
authors.affiliation: Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Kirk J
authors.initials: KJ
authors.lastname: Pak
authors.affiliation: Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA.
authors.forename: Tian
authors.initials: T
authors.lastname: Hu
authors.affiliation: Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA.
authors.forename: Colin
authors.initials: C
authors.lastname: Fee
authors.affiliation: The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Richard
authors.initials: R
authors.lastname: Wang
authors.affiliation: The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Morgan
authors.initials: M
authors.lastname: Smith
authors.affiliation: Department of Internal Medicine, Ochsner Clinic Foundation, New Orleans, LA ; Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
authors.forename: Lydia A
authors.initials: LA
authors.lastname: Bazzano
keywords: Acute disease; arterial pressure; blood pressure; emergency treatment; hypertension–malignant; practice guidelines as topic