Acute pharmacologic treatment versus observation for severe asymptomatic hypertension in emergency and acute care settings: a systematic review of short-term outcomes

Severe asymptomatic hypertension is commonly encountered in acute care settings, yet optimal management remains uncertain. Markedly elevated blood pressure frequently prompts immediate pharmacologic treatment despite limited comparative evidence that such treatment improves short-term clinical outcomes. We conducted a systematic review to evaluate immediate pharmacologic blood pressure lowering versus conservative or observational management in adults with severe hypertension without acute target-organ damage. PubMed, Embase, Web of Science, and Scopus were searched from inception to January 2026. Comparative studies enrolling adult patients without acute target-organ damage in emergency department (ED) or inpatient acute care settings were included. The primary outcome was short-term adverse clinical events within 7 days. Because of substantial clinical and methodological heterogeneity, findings were synthesized narratively, with ED and inpatient evidence evaluated separately. Seven studies, including one randomized controlled trial and six observational studies, met the inclusion criteria. Among ED populations, major adverse cardiovascular events were uncommon, and immediate pharmacologic treatment was not associated with a consistent reduction in adverse events or healthcare utilization within 7 days. One randomized trial found similar short-term reductions in blood pressure with oral antihypertensive therapy and with rest alone. In hospitalized patients who developed severe hypertension during admission for unrelated conditions, observational studies found that intravenous antihypertensive therapy was associated with a greater likelihood of excessive blood pressure reduction and myocardial injury. These inpatient findings arose from overlapping cohorts and remain susceptible to residual confounding by indication. Available evidence does not demonstrate a consistent short-term clinical benefit of immediate pharmacologic blood pressure lowering in adults with severe hypertension without acute target-organ damage. Observational inpatient data identify potential safety signals associated with intravenous therapy, but these associations should not be interpreted as causal or directly extrapolated to ED populations. Further well-designed prospective studies are needed.