From the Guidelines
For rebound hypertension after enalapril 2.5 mg IV, alternative agents such as labetalol or nicardipine are preferred due to the potential for enalaprilat to cause rebound hypertension, as seen in the case of clonidine 1. Given the patient's response to enalapril and subsequent rebound hypertension, it is crucial to consider alternative intravenous antihypertensive agents that can provide a more controlled reduction in blood pressure. The choice of agent depends on various factors including the patient's comorbidities, the presence of end-organ damage, and the desired rate of blood pressure decline. Some key options for managing rebound hypertension in the emergency department include:
- Labetalol, which can be administered as a 10-20 mg IV bolus, repeated every 10 minutes as needed, with a maximum dose of 300 mg 1
- Nicardipine, which can be started as a 5 mg/hour infusion, titrated by 2.5 mg/hour every 5-15 minutes, with a maximum dose of 15 mg/hour 1
- Other agents like clevidipine, fenoldopam, or nitroglycerin may also be considered based on the patient's specific clinical scenario and comorbidities 1 It is essential to monitor blood pressure frequently and assess for end-organ damage when managing rebound hypertension, aiming for a controlled reduction in blood pressure rather than rapid normalization, typically reducing mean arterial pressure by no more than 25% in the first hour to avoid hypoperfusion 1.
From the Research
Management of Rebound Hypertension
- Rebound hypertension can occur after initial blood pressure control with enalapril 2.5 mg IV 2.
- In such cases, alternative agents like nicardipine or clevidipine can be considered for blood pressure control 2.
- Nicardipine has been shown to achieve sustained systolic blood pressure control with a lower risk of rebound hypertension compared to clevidipine 2.
Treatment Options for Hypertensive Emergencies
- The management of hypertensive emergencies requires immediate treatment to prevent end-organ damage 3, 4.
- A symptoms- and evidence-based algorithm, such as the BARKH-based algorithm, can be used for the assessment and treatment of patients with hypertensive emergencies 3.
- Intravenous agents like nicardipine or clevidipine can be used for rapid blood pressure control in patients with hypertensive emergencies 2, 3.
Clinical Outcomes in Hypertensive Emergencies
- Hypertensive emergencies can result in significant morbidity and mortality, with a prevalence of 0.5% in all patients presenting to the emergency department 5.
- The most common hypertension-mediated organ damage in patients with hypertensive emergencies includes ischemic stroke, pulmonary edema/acute heart failure, and hemorrhagic stroke 5.
- In-hospital mortality among patients with hypertensive emergency can be as high as 9.9% 5.