What is the treatment for acute hypertension?

From the Guidelines

Acute hypertension should be treated promptly with intravenous labetalol, nicardipine, or clevidipine to reduce blood pressure by no more than 25% within the first hour, with the goal of minimizing target organ damage and improving quality of life. The choice of medication depends on the presence of comorbidities, such as acute aortic dissection, acute coronary syndromes, or eclampsia, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

For patients with acute aortic dissection, esmolol or labetalol are preferred to rapidly lower systolic blood pressure to <120 mmHg, with beta blockade preceding vasodilator administration if needed 1. In patients with acute coronary syndromes, esmolol, labetalol, nicardipine, or nitroglycerin may be used, with caution to avoid contraindications such as beta blockers in patients with moderate-to-severe left ventricular failure or bradycardia 1.

The European Heart Journal's 2019 position document on the management of hypertensive emergencies also recommends labetalol as a first-line treatment for various clinical presentations, including malignant hypertension, hypertensive encephalopathy, and acute ischemic stroke 1. The goal is to reduce blood pressure while minimizing the risk of cerebral, cardiac, or renal hypoperfusion, and to transition to oral antihypertensive medications after stabilization.

Key considerations in the treatment of acute hypertension include:

• Continuous monitoring of vital signs, neurological status, urine output, and ECG
• Identification and addressing of the underlying cause of hypertension
• Avoidance of too rapid reduction in blood pressure to prevent hypoperfusion
• Transition to oral antihypertensive medications with appropriate follow-up to ensure long-term blood pressure control.

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 indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable.

Acute Hypertension Treatment Options:

• Sodium Nitroprusside (IV): indicated for immediate reduction of blood pressure in hypertensive crises 2
• Nicardipine (IV): indicated for short-term treatment of hypertension when oral therapy is not feasible or desirable 3

Key Considerations:

• Concomitant longer-acting antihypertensive medication should be administered with sodium nitroprusside to minimize treatment duration 2
• Nicardipine hydrochloride injection should be titrated to achieve desired blood pressure reduction, with a maximum infusion rate of 15 mg/hr 3

From the Research

Acute Hypertension Treatment

• Acute hypertension treatment depends on the presence or absence of target organ damage, with hypertensive emergencies requiring immediate treatment with intravenous antihypertensive medications 4.
• Hypertensive emergencies include conditions such as acute aortic dissection, hypertensive encephalopathy, acute myocardial ischemia, severe pulmonary edema, eclampsia, and acute renal failure 5.
• The management of patients with hypertensive emergencies must be ensured in an intensive care unit, and must include the parenteral administration of antihypertensive drugs and accurate blood pressure monitoring 5.
• For patients with severely elevated blood pressure but without symptoms, management starts with long-acting antihypertensive drugs, typically a combination of a renin-angiotensin system inhibitor, a thiazide diuretic, and/or a calcium channel blocker 6.

Medications Used

• Clevidipine, a dihydropyridine calcium channel antagonist, is effective in the treatment of acute hypertension, particularly in the perioperative setting 7.
• Nicardipine, another dihydropyridine calcium channel blocker, has been compared to clevidipine in terms of efficacy and safety for blood pressure control in hypertensive crisis, with results showing no difference in initial blood pressure control but more sustained systolic blood pressure control with nicardipine 8.
• Sodium nitroprusside and nitroglycerin are also used in the treatment of acute hypertension, although clevidipine has been shown to be more effective in certain settings 7.

Treatment Goals

• The goal of treatment for hypertensive emergencies is to reduce mean arterial pressure by no more than 20% during the first few hours, to avoid inducing severe ischemic injury in major organs 5.
• For patients with asymptomatic severe hypertension, the goal is to achieve a target blood pressure level through the use of long-acting antihypertensive drugs 6.
• In the setting of hypertensive crisis, the goal is to achieve a 25% reduction in mean arterial pressure at 1 hour, and a systolic blood pressure of <160 mm Hg at 2-6 hours from the start of the infusion 8.