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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e181 antihypertensive drug class provides more benefit than harm in hypertensive emergencies. This lack of high-quality RCT evidence is related to the small size of trials, lack of double-blinding design, lack of longterm follow-up, and failure to report outcomes. The therapeutic goal is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment. To achieve rapid BP control and avoid large swings in BP, continuous infusion of short-acting titratable antihy pertensive agents is often preferable in the intensive care setting. Antihypertensive agents available for the treatment of hypertensive emergencies are shown in Tables 26 and 27. Clinical trials suggested that IV nicardipine is more effective than labetalol in reach ing short-term BP target, while clevidipine was shown to induce faster reduction in BP than nicardipine.1,2 However, selection of an antihypertensive agent should be based on the drug’s pharmacology, under lying mechanisms of hypertension, degree of progres sion of target organ damage, the desirable rate of BP decline, and the presence of comorbidities. 2. Other than for stroke/ICH (Section 5.3.9, “Cerebrovascular Disease”), there is no RCT evi dence comparing different strategies to reduce BP acutely. Observational studies have indicated expo nential dose-response relationship between SBP and an increasing risk of aortic dissection and death, with an HR of more than 2-fold for SBP >120 mm Hg.4 However, BP measurement was not per formed during hospitalization or IV drug treatment. Nevertheless, the current guideline endorses SBP target to <130 mm Hg in most patients with AD and <120 mm Hg in selected high-risk patients in the chronic setting.14 Pheochromocytoma hyperten sive crisis is also considered a medical emergency that requires prompt lowering of BP. However, the relationship between BP and mortality risk has not been characterized during adrenergic crisis. Despite potential cardiovascular complications of pheochro mocytoma crisis, including a takotsubo-like car diomyopathy,5 pheochromocytoma should not be considered a compelling indication to reduce SBP immediately to less than <120 or 140 mm Hg in the first hour. In addition, clinical trials in patients with out aortic dissection or pheochromocytoma showed increased risk of adverse kidney events associated with early intensive lowering of SBP to 110 to 139 mm Hg, particularly among patients with extremely high initial SBP of >220 mm Hg.6,7 Thus, an attempt should be made to reduce SBP to <120 mm Hg in aortic dissection during the first hour and <140 mm Hg for most other conditions while monitoring for the presence and extent of other target organ function. 3. There is no RCT evidence for the treatment of other forms of hypertensive emergency without compelling indication. Small clinical trials in patients with acute HF and severe hypertension showed improvement in dyspnea when SBP was reduced by 15% (ie, 20 to 40 mm Hg) within 30 minutes without increased adverse events.2,9 Thus, strate gies to reduce BP should be more conservative to achieve 25% reduction in the first hour, followed by gradual further reduction within 24 to 48 hours. 4. Antihypertensive drug treatment should be used with extreme caution in hospitalized patients with asymp tomatic severe hypertension because spontaneous falls in BP without any antihypertensive agents occur commonly, at a rate of 40% to 50%.10 Observational studies have shown that initiation or intermittent use of additional IV or oral antihypertensive medications in patients hospitalized for noncardiac conditions are associated with increased risk of in-hospital mortal ity, AKI, and prolonged hospital stay.8,11 Asymptomatic patients with severe hypertension can be treated with careful and frequent monitoring using standing medi cations and avoiding as-needed medications. 6.2.1 Medications for Hypertensive Emergencies Treatment of hypertensive emergencies requires rapid recognition of the condition and knowledge of the unique treatment approaches appropriate for the causal condition or emergency consequences. A full discussion of these factors are in Sections 6.2 (“Hypertensive Emergencies and Severe Hypertension in Nonpregnant and Nonstroke Patients”) and 5.3.9 (“Cerebrovascular Disease”). Tables 26 and 27 provide preferred agents for specific conditions. 6.3 Sexual Dysfunction Synopsis Sexual dysfunction frequently occurs in individuals with hy pertension and has been more commonly reported by wom en than men.1–6 Sexual dysfunction is defined as a person’s inability to participate in sexual relationships as they would wish7 and can be assessed in men and women using sexspecific validated tools that query emotional and physical symptoms in several domains, including thoughts and de sires, arousal, frequency of sexual activity, pleasure and or gasm, and problems affecting sexual function.8,9 The asso ciation between hypertension and sexual dysfunction may be due to shared mechanistic pathways of impaired vascu lar function and atherosclerosis, in addition to common risk factors of increasing age, hormonal shifts, diabetes, and de pression.10 Antihypertensive medications may also contrib ute as treated patients with hypertension are more likely to report sexual dysfunction than untreated ones.11 Discussing sexual function with patients is essential as concerns about antihypertensive medications’ negative impact on sexual function can lead to decreased adherence.12 Diuretics and BBs, except nebivolol, are most commonly associated with erectile dysfunction in men,10 and BBs are associated with a worsening of sexual function in women.13,14 ARBs have the most favorable profile in men and women.6,10 Phospho Downloaded from http://ahajournals.org by on October 7, 2026