What is the next best step to manage a patient with severe hypertension (Blood Pressure 193/95) who has already received lobetalol (20 mg) after initial treatment with lisinopril (40 mg) and metoprolol (100 mg), and presented with abdominal pain?

From the Guidelines

For this patient with persistent hypertension despite initial labetalol treatment, I would recommend administering nitroprusside or nicardipine as alternative options, as suggested by the European Heart Journal study 1. Given the patient's already high doses of lisinopril and metoprolol at home with inadequate control, and partial response to labetalol, additional antihypertensive therapy is warranted. Some key points to consider in this scenario include:

• The patient's blood pressure is still elevated at 193/95, indicating the need for further intervention.
• The European Heart Journal study 1 suggests that nitroprusside or nicardipine can be used as alternative treatments for hypertensive emergencies.
• It's essential to monitor the patient closely for hypotension, reflex tachycardia, or other adverse effects while administering these medications.
• Investigating the underlying cause of the abdominal pain is crucial, as this could be contributing to the blood pressure elevation.
• Considering the patient's adherence to her home medications is also important, as non-adherence is a common cause of uncontrolled hypertension. The administration of these medications should be done with caution, and the patient's blood pressure should be closely monitored to avoid precipitous drops in blood pressure, as noted in the study 1.

From the FDA Drug Label

The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0.1 mg/mL. With constant infusion, blood pressure begins to fall within minutes. It reaches about 50% of its ultimate decrease in about 45 minutes 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.

The patient's blood pressure is elevated at 193/95 after initial treatment with lobetalol. Nicardipine hydrochloride injection can be considered as an additional treatment option.

• The initial infusion rate can be set at 5 mg/hr.
• The infusion rate can be increased by 2.5 mg/hr every 15 minutes if the desired blood pressure reduction is not achieved, up to a maximum of 15 mg/hr.
• The patient's blood pressure and heart rate should be closely monitored during and after the infusion to avoid tachycardia or too rapid or excessive reduction in either systolic or diastolic blood pressure 2, 2, 2.

From the Research

Hypertensive Emergency Management

The patient's condition, with a blood pressure of 219/108 and abdominal pain, suggests a hypertensive emergency. According to 3, hypertensive emergencies are uncommon and require immediate attention. The patient has already been given labetalol 20 mg, which lowered her blood pressure to 166/90, but it has since increased to 193/95.

Treatment Options

Considering the patient's condition and the initial response to labetalol, the following treatment options can be considered:

• Sodium nitroprusside: As mentioned in 3 and 4, sodium nitroprusside is a commonly used agent for hypertensive emergencies, but it should be used with caution in patients with impaired cerebral flow.
• Nitroglycerin: As discussed in 4 and 5, nitroglycerin is useful in patients prone to myocardial ischemia, but it should be avoided in patients with increased intracranial pressure.
• Nicardipine: According to 4 and 6, nicardipine is a potent arteriolar vasodilator that can be used in hypertensive emergencies, but it should not be used in patients with severe aortic stenosis.
• Clevidipine: As mentioned in 6 and 7, clevidipine is a novel, rapidly acting dihydropyridine L-type calcium channel blocker that can be used in hypertensive emergencies, particularly in cardiac surgery patients.

Key Considerations

When managing hypertensive emergencies, it is essential to:

• Monitor blood pressure closely and avoid acute reductions in mean arterial pressure (MAP) of more than 20% whenever possible 3.
• Be aware of the potential adverse effects of each agent and use them cautiously in patients with specific comorbidities 4.
• Consider the patient's underlying condition and choose an agent that is appropriate for their specific needs 6.