From the Guidelines
Hypertensive crisis is a severe elevation in blood pressure requiring immediate medical attention, and treatment should be guided by the presence or absence of organ damage, with the goal of minimizing morbidity, mortality, and improving quality of life.
Key Considerations
- The management of hypertensive emergencies is primarily driven by the type of acute organ damage, with the goal of preventing or limiting further damage through controlled blood pressure reduction 1.
- Patients with hypertensive emergencies should be admitted for close monitoring and treated with intravenous blood pressure-lowering agents to reach the recommended blood pressure target in the designated time-frame 1.
- The choice of intravenous antihypertensive drug depends on the specific comorbidity, with options including labetalol, nicardipine, clevidipine, and nitroglycerin 1.
Treatment Approach
- For hypertensive emergencies, immediate IV medications like labetalol (20-80 mg bolus every 10 minutes), nicardipine (5-15 mg/hr), or clevidipine (1-2 mg/hr) are recommended to lower blood pressure by 20-25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours 1.
- For hypertensive urgency, oral medications like captopril (25 mg), labetalol (200-400 mg), or amlodipine (10 mg) can be used to gradually reduce blood pressure over 24-48 hours 1.
Monitoring and Underlying Cause
- Patients should be monitored closely for signs of organ damage, including headache, vision changes, chest pain, shortness of breath, or neurological symptoms 1.
- The underlying cause of the hypertensive crisis should be identified and addressed, which may include medication non-adherence, renal disease, or endocrine disorders 1.
Quality of Life and Morbidity Considerations
- Rapid blood pressure reduction can cause organ hypoperfusion, so controlled reduction is essential to prevent complications like stroke, heart failure, or renal failure 1.
- The goal of treatment is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment, ultimately improving quality of life and reducing morbidity and mortality 1.
From the FDA Drug Label
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.
In other settings (e.g., patients with severe or postoperative hypertension), nicardipine hydrochloride injection (5 to 15 mg/hr) produced dose-dependent decreases in blood pressure. Higher infusion rates produced therapeutic responses more rapidly The mean time to therapeutic response for severe hypertension, defined as diastolic blood pressure less than or equal to 95 mmHg or greater or equal to 25 mmHg decrease and systolic blood pressure less than or equal to 160 mmHg, was 77 ± 5 minutes.
Nicardipine (IV) can be used to treat hypertensive crisis. The initial dose is 5 mg/hr, which can be increased by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr. For more rapid blood pressure reduction, the dose can be titrated every 5 minutes 2. In patients with severe hypertension, nicardipine hydrochloride injection at a dose of 5 to 15 mg/hr has been shown to produce dose-dependent decreases in blood pressure, with a mean time to therapeutic response of 77 ± 5 minutes 2.
Sodium nitroprusside (IV) is also indicated for the immediate reduction of blood pressure in hypertensive crises 3.
From the Research
Definition and Classification of Hypertensive Crisis
- A hypertensive crisis is defined as a systolic blood pressure (BP) > 180 mm Hg or a diastolic BP > 120 mm Hg 4, 5, 6
- Hypertensive crises are categorized as either hypertensive emergencies or urgencies, depending on the degree of BP elevation and presence of end-organ damage 4, 5, 6
Treatment of Hypertensive Crisis
- The primary goal of intervention in a hypertensive crisis is to safely reduce BP 4, 6
- Immediate reduction in BP is required only in patients with acute end-organ damage (i.e., hypertensive emergency) 4, 5, 6
- Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents 4, 5, 6
- Rapid-acting IV antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 4, 5, 6, 7, 8
Medications to Avoid
- Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 4, 5, 6
- Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to significant toxicities and/or side effects 4, 5, 6