Management Strategies for Hypertensive Crises: A Systematic Review of Evidence-Based Approaches.

Hypertensive crises, encompassing emergencies and urgencies, are acute, severe blood pressure elevations associated with significant morbidity and mortality. Despite available guidelines, variability in clinical practice persists. This systematic review aims to synthesise evidence on pharmacological management strategies for hypertensive crises, focusing on efficacy, safety, and setting-specific considerations. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a comprehensive search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library was conducted for studies published between January 2020 and December 2025. Studies evaluating pharmacological interventions in adult patients with hypertensive crises were included. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). A narrative synthesis was performed due to clinical and methodological heterogeneity. The search yielded 629 records, of which six studies met the inclusion criteria, with two randomised controlled trials, two retrospective cohort studies, and two cross-sectional studies conducted across India, Taiwan, the United States, Ethiopia, the Netherlands, and Europe. All studies demonstrated low risk of bias, with NOS scores ranging from 7 to 9 stars. Continuous intravenous infusion achieved the fastest blood pressure reduction, while intravenous bolus alone was associated with the shortest intensive care unit (ICU) stay. One study found no significant difference in time to blood pressure control between treated and untreated emergency department patients, but observed reduced three-year and five-year mortality in treated patients. Overall mortality among ICU patients was 8%, with higher rates in those presenting with acute coronary syndrome. Both phenoxybenzamine and doxazosin were effective in preventing intraoperative haemodynamic instability during pheochromocytoma resection, with zero 30-day mortality. Acute kidney injury occurred in 20-30% of patients with hypertensive emergencies complicated by heart failure. Guidelines recommended against routine early intensive blood pressure lowering in acute ischaemic stroke due to the absence of proven mortality benefit and potential harm. Factors associated with better outcomes included polypharmacy approaches, formal end-organ damage evaluation, and absence of target organ damage. Multiple pharmacological strategies are effective in hypertensive crises, with choice guided by clinical context and target organ damage. Continuous infusion offers the fastest reduction, and bolus strategies reduce ICU utilisation. Target organ damage, especially acute coronary syndrome, predicts worse outcomes. Emergency department intervention confers long-term mortality benefits. Standardised definitions and larger trials are needed, particularly in resource-limited settings.