What is the next best step for a patient with severe hypertension and abdominal pain, currently on lisinopril (Angiotensin-Converting Enzyme Inhibitor) 40 mg and metoprolol (Beta Blocker) 100 mg, who received labetalol (Beta Blocker) 20 mg with initial response, but now has worsening hypertension and elevated B-type Natriuretic Peptide (BNP) levels?

From the Guidelines

For this patient with persistently elevated blood pressure despite home medications and initial labetalol dose, I recommend administering another dose of IV labetalol 20-40 mg or considering IV nicardipine infusion starting at 5 mg/hour, titrating as needed, as suggested by the European Heart Journal study 1 and further supported by the esc council on hypertension position document 1. The patient's severely elevated initial blood pressure (219/108) despite being on lisinopril and metoprolol indicates inadequate control, and the partial response to labetalol suggests she would benefit from additional short-acting antihypertensive therapy to achieve target blood pressure while the underlying cause of her hypertensive urgency is investigated. Key considerations in managing this patient include:

• Monitoring her blood pressure closely and adjusting antihypertensive therapy as needed to avoid large reductions in blood pressure that could lead to ischemic stroke or death, as warned by 1.
• Evaluating her abdominal pain, which could be contributing to her hypertension, and addressing any underlying causes.
• Considering the elevated BNP of 256, which suggests possible heart failure contribution, and monitoring her fluid status carefully, with potential addition of IV furosemide 20-40 mg if signs of volume overload are present.
• Reassessing her outpatient regimen once stabilized, as she may need additional or adjusted antihypertensive medications to achieve better blood pressure control, taking into account the guidelines provided by 1.

From the FDA Drug Label

Cleviprex is intended for intravenous use. Titrate Cleviprex to achieve the desired blood pressure reduction. Individualize dosage depending on the blood pressure response of the patient and the goal blood pressure. Initial dose: Initiate intravenous infusion of Cleviprex at 1- 2 mg/hour. Dose titration: Double the dose at short (90 second) intervals initially. As the blood pressure approaches goal, increase the dose by less than doubling and lengthen the time between dose adjustments to every 5-10 minutes.

The patient's blood pressure is elevated at 193/95, and she has already been given lobetalol. Considering her current medication regimen, including lisonapril and metoprolol, and the fact that her blood pressure is not adequately controlled, clevidipine (IV) could be a potential option to help reduce her blood pressure.

• The initial dose of clevidipine is 1-2 mg/hour.
• The dose can be titrated to achieve the desired blood pressure reduction, with doubling of the dose at short intervals initially, and then lengthening the time between adjustments as the blood pressure approaches the goal.
• It is essential to monitor blood pressure and heart rate during the infusion and until vital signs stabilize 2, 2.

From the Research

Patient Assessment

• The patient's blood pressure is 219/108, which is considered hypertensive.
• The patient is experiencing abdominal pain and has a history of hypertension, currently being treated with lisonapril 40 mg and metoprolol 100 mg.
• The patient's BNP is 256, which may indicate cardiac strain.

Treatment Options

• The patient was initially given labetalol 20 mg, which lowered their blood pressure to 166/90.
• However, 20 minutes later, the patient's blood pressure began to rise again to 193/95.
• Considering the patient's renal function is not explicitly mentioned, but their BNP is elevated, it is crucial to choose an antihypertensive agent that is safe and effective in this context.
• According to the study 3, labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside are rapid-acting intravenous antihypertensive agents that can be used to treat hypertensive emergencies.
• The study 4 suggests that nicardipine may provide more predictable and consistent blood pressure control than labetalol.
• The study 5 found that nicardipine was more efficacious than labetalol in achieving target blood pressure range within 30 minutes in patients with renal dysfunction.

Potential Next Steps

• Consider administering nicardipine as an alternative to labetalol, given its potential for more predictable blood pressure control 4, 5.
• Monitor the patient's blood pressure and renal function closely, as well as their cardiac status given the elevated BNP.
• Consult with a cardiologist or intensivist to determine the best course of treatment for this patient's specific condition.