What is the management of hypertensive crisis?

From the Guidelines

Hypertensive crisis management requires immediate intervention to prevent organ damage, with a focus on controlled blood pressure reduction to safer levels without risk of hypotension, as recommended by the most recent guidelines 1.

Key Principles

• For hypertensive emergency (BP >180/120 with evidence of end-organ damage), administer IV medications in a monitored setting, with first-line options including labetalol or nicardipine, as suggested by the European Heart Journal study 1.
• Target a controlled blood pressure reduction, avoiding excessive drops that could cause hypoperfusion, with the goal of preventing or limiting further hypertensive damage.
• For hypertensive urgency (severely elevated BP without organ damage), oral medications like captopril, labetalol, or nifedipine retard can be used, with BP rechecks within 30-60 minutes, as proposed by the European Heart Journal study 1.

Treatment Approach

• The choice of antihypertensive treatment is predominantly determined by the type of organ damage, with specific clinical presentations of hypertensive emergencies including malignant hypertension, hypertensive encephalopathy, and hypertensive thrombotic microangiopathy, as outlined in the 2020 International Society of Hypertension global hypertension practice guidelines 1.
• Intravenous therapy is usually required for hypertensive emergencies, with labetalol and nicardipine being widely available and recommended options 1.
• Oral antihypertensive therapy can be used for patients with substantially elevated BP who lack acute end-organ damage, with close monitoring and follow-up, as suggested by the 2020 International Society of Hypertension global hypertension practice guidelines 1.

Monitoring and Follow-up

• Monitor for complications including stroke, myocardial infarction, acute kidney injury, and encephalopathy, and identify and treat underlying causes such as medication non-adherence, pain, anxiety, or secondary hypertension.
• After stabilization, transition to oral antihypertensives and arrange close follow-up within 24-72 hours, with a focus on long-term blood pressure control and management, as recommended by the European Heart Journal study 1.

From the FDA Drug Label

Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2. 5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved.

Hypertensive Crisis Management:

• Sodium Nitroprusside: indicated for immediate reduction of blood pressure in hypertensive crises 2.
• Nicardipine: administered by slow continuous infusion, with a starting dose of 5 mg/hr, titrated every 15 minutes as needed, up to a maximum of 15 mg/hr 3. The choice of medication and dosage should be individualized based on the patient's condition and response to treatment. In cases of severe hypertension, higher infusion rates of nicardipine may be required, with an average maintenance dose of 8.0 mg/hr 3.

From the Research

Definition and Classification of Hypertensive Crisis

• A hypertensive crisis is defined as a sudden and significant rise in blood pressure, with a reading of 180/120 mmHg or higher 4
• It can be classified as either a hypertensive emergency or urgency, depending on the degree of blood pressure elevation and presence of end-organ damage 5, 6

Management of Hypertensive Emergencies

• Patients with hypertensive emergencies require immediate admission to an intensive care unit for continuous monitoring of blood pressure and prompt treatment with parenteral anti-hypertensive drugs 5, 6, 7, 8
• The goal is to reduce blood pressure by about 10% in the first hour and another 15% over the next 2-3 hours to prevent cerebral hypoperfusion 7
• Rapid-acting intravenous antihypertensive agents such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine are commonly used 5, 6, 4

Management of Hypertensive Urgencies

• Patients with hypertensive urgencies can be treated with oral anti-hypertensive agents, with a goal of reducing blood pressure over 12-24 hours 5, 6, 8
• The treatment approach should be based on the underlying pathophysiological and clinical findings, as well as the mechanism of action and potential side effects of the chosen agent 8

Treatment Options

• Intravenous esmolol is recommended for patients with acute aortic dissection, with a goal of reducing systolic blood pressure to less than 120 mmHg within 5-10 minutes 4
• Vasodilators such as nitroglycerin or nitroprusside may be used if blood pressure persists after beta blockade 4
• Clevidipine, nicardipine, or phentolamine may be used as alternative agents, with an initial dose of 5 mg and subsequent doses given every 10 minutes as needed 4

Important Considerations

• Sodium nitroprusside is an extremely toxic drug and its use should be avoided in the treatment of hypertensive emergencies 5, 6
• Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to their significant toxicities and/or adverse effects 5, 6