What is the management of acute hypertension?

From the Guidelines

Management of acute hypertension should prioritize immediate IV medications for hypertensive emergencies, with careful consideration of the underlying cause and potential end-organ damage, as recommended by the most recent guidelines 1. The goal of treatment is to reduce mean arterial pressure by no more than 25% within the first hour, while minimizing the risk of hypoperfusion.

• For patients with acute intracerebral haemorrhage, immediate BP lowering is not recommended for patients with systolic BP <220 mmHg, but careful acute BP lowering with i.v. therapy to <180 mmHg should be considered for those with systolic BP ≥220 mmHg 1.
• In hypertensive patients with an acute cerebrovascular event, anti-hypertensive treatment is recommended immediately for TIA, and after several days in ischemic stroke 1.
• First-line IV medications for severe hypertension include labetalol, oral methyldopa, or nifedipine, with intravenous hydralazine as a second-line option 1.
• Continuous monitoring is essential during treatment, with frequent vital sign checks and assessment for signs of hypoperfusion, to balance the risks of hypertension against those of overly aggressive treatment 1. Key considerations in the management of acute hypertension include:
• Identifying and addressing the underlying cause of hypertension
• Careful titration of medications to avoid rapid blood pressure reduction
• Monitoring for signs of end-organ damage and hypoperfusion
• Individualizing treatment based on the patient's specific clinical presentation and comorbidities 1.

From the FDA Drug Label

Titration 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. For more rapid blood pressure reduction, titrate every 5 minutes. When treating acute hypertensive episodes in patients with chronic hypertension, discontinuation of infusion is followed by a 50% offset of action in 30 minutes ± 7 minutes but plasma levels of drug and gradually decreasing antihypertensive effects exist for many hours.

The management of acute hypertension with nicardipine (IV) involves:

• Initiating therapy at a rate of 5 mg/hr for a gradual reduction in blood pressure
• Increasing 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
• Titrating every 5 minutes for more rapid blood pressure reduction
• Monitoring closely and adjusting the infusion rate as needed to maintain desired response 2

From the Research

Management of Acute Hypertension

• Acute hypertensive episodes can be defined as severe spikes in blood pressure that may result in end-organ damage 3
• Hypertensive crises are further defined as either hypertensive emergencies or urgencies, depending on the degree of blood pressure elevation and presence of end-organ damage 4
• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, with the appropriate therapeutic approach depending on the patient's clinical presentation 4

Treatment Options

• Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e. hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent 4
• Severe hypertension without acute end-organ damage (i.e. hypertensive urgency) is usually treated with oral antihypertensive agents 4
• Rapid-acting intravenous antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside 4
• Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages over other available agents in the management of hypertensive crises 4, 3
• Nicardipine and labetalol have been shown to have comparable efficacy and safety in the treatment of hypertensive crises, although nicardipine may provide more predictable and consistent blood pressure control 5

Considerations for Treatment

• The choice of oral versus parenteral drug depends on the urgency of the situation, as well as the patient's general condition 6
• The level to which the blood pressure should be lowered varies with the type of hypertensive crisis and should be individualized 6
• Complications of therapy, mainly hypotension and ischemic brain damage, can occur in patients given multiple potent antihypertensive drugs in large doses without adequate monitoring 6
• Gentle lowering of blood pressure, careful surveillance, and individualization of therapy can help minimize complications 6