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CLINICAL STATEMENTS AND GUIDELINES September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e180 hypertension trials (31 043 participants with 275 098 assessments for OH), have together shown that more intensive BP treatment and active antihypertension treatment lower the risk for OH.1–3 In SPRINT, there was an increase in self-reported syncope for inten sively treated participants; however, the intensively treated group experienced no increase in falls or injurious falls but rather a nonstatistically significant decrease in injurious falls. This finding was the same for the intensively treated arm in the CRHCP (goal for both trials <120 mm Hg).4,18 2 The impact of OH on the CVD and mortality ben efit from intensive BP control in the SPRINT trial found no difference in the risk reduction for CVD or all-cause mortality, regardless of OH status, and no evidence for harm among those with stand ing hypotension (SBP <110 mm Hg).3 A similar post-hoc analysis of the NAILED (Nurse-Based Age-Independent Intervention to Limit Evolution of Disease) study population (n=814, 35% expe riencing OH at least once) showed that intensifi cation of BP control was not associated with an increased risk of cardiovascular events or death in this stroke/TIA population.5 Systematic titra tion of antihypertensive treatment did not increase the prevalence of OH compared with usual care. Thus, there is emerging evidence that OH does not reduce the gains of intensive antihypertensive treatment. 3. Assessment for OH prior to initiation of treatment is equitable as this was part of the eligibility pro cess for the most valid trials of BP lowering.1–4,18 An assessment for OH in symptomatic patients, particularly after initiation of treatment or add ing a new class of antihypertensive medication, is acceptable to detect unmasked autonomic system dysfunction or other acute or chronic conditions.6,7 6.2 Hypertensive Emergencies and Severe Hypertension in Nonpregnant and Nonstroke Patients Recommendations for Hypertensive Emergencies and Severe Hypertension in Nonpregnant and Nonstroke Patients* References that support recommendations are summarized in the Evidence Table. COR LOE Recommendations 1 B-NR 1 In adults with a hypertensive emergency (BP >180 and/or >120 mm Hg and evidence of acute target organ damage), admission to an intensive care unit is recommended for continu ous monitoring of BP and target organ damage and for consideration of parenteral administra tion of appropriate therapy (Tables 26 and 27, Figure 9).1–3 1 C-LD 2 For adults with a hypertensive emergency related to a compelling condition (eg, acute aortic syndrome or acute aortic dissection), SBP should be reduced to <140 mm Hg for most conditions and to <120 mm Hg in aortic dissection during the first hour, while monitoring for other target organ dysfunction.4–7 1 C-LD 3 For adults with a hypertensive emergency but with out a compelling condition, SBP should be reduced with oral or parenteral therapy by no more than 25% within the first hour; then, if stable, to <160/100 mm Hg within the next 2 to 6 hours; and then cau tiously to 130 to 140 mm Hg during the next 24 to 48 hours to limit target organ injury.2,8,9 3: Harm B-NR 4 For adults with severe hypertension (>180/120 mm Hg) who are hospitalized for noncardiac conditions without evidence of acute target organ damage, intermittent use of additional IV or oral antihyperten sive medications are not recommended to acutely reduce BP.8,10,11 *Hypertensive emergencies in patients with acute ICH and acute ischemic stroke are discussed in Section 5.3.9 (“Cerebrovascular Disease”) and in preg nant adults in Section 11.5 (“Hypertension and Pregnancy”). Synopsis Hypertensive emergencies are defined as severe eleva tions in BP (>180/120 mm Hg) associated with evidence of acute target organ damage. Patients with hypertensive emergencies experience a high in-hospital mortality rate of 10% with a 1-year cardiovascular morbidity and mor tality rate of 20% to 30%.12,13 Common forms of acute hypertension-related target organ damage include acute HF/pulmonary edema, neurologic disorders (encepha lopathy, ICH, acute ischemic stroke), and AKI, with aortic dissection the least common presentation.12 Hypertensive emergencies demand immediate reduction of BP to pre vent or limit further target organ damage. However, the rapid correction of BP in patients with longstanding hy pertension to normal range may result in vital organ hypo perfusion due to loss of autoregulation.6,7 In contrast, pa tients with severe hypertension without evidence of acute target organ damage (previously called hypertensive ur gency) should not have aggressive BP lowering in the short-term or be given parenteral antihypertensive drug therapy. Reinstitution or intensification of oral antihyper tensive medications, preferably in the outpatient setting, is recommended for these patients. Recommendation-Specific Supportive Text 1 There is no RCT evidence that antihypertensive drugs reduce morbidity or mortality in patients with hyper tensive emergencies.3 There is also no high-quality RCT evidence to inform clinicians as to which first-line Recommendations for Hypertensive Emergencies and Severe Hypertension in Nonpregnant and Nonstroke Patients* (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026