Elevated blood pressure per se in the absence of signs or symptoms of target organ damage does not constitute a hypertensive emergency or urgency. Rapidly and overly aggressively reducing blood pressure in a patient with incidentally discovered elevated blood pressure is potentially harmful and may produce complications, such as coronary or cerebral hypoperfusion syndromes. Examples of true hypertensive emergencies in older patients include hypertensive encephalopathy, acute heart failure with pulmonary edema, dissecting aortic aneurysm, and unstable angina. These situations will present with symptoms and signs of vascular compromise of the affected organs. The management of these emergencies requires an acute hospital setting, with the parenteral administration of an antihypertensive agent and continuous blood-pressure monitoring to achieve an immediate reduction in blood pressure, although not initially to a normal target level. Blood pressure should not be lowered emergently more than 25% within the first 2 hours, with a goal of achieving 160/100 mm Hg gradually over the first 6 hours of therapy. Hypertensive urgencies, situations in which blood pressure should be lowered within 24 hours to prevent the risk of target organ damage, are more common than true emergencies. The majority may be managed with oral administration of antihypertensive medications to achieve a gradual blood-pressure reduction.