From the Guidelines
To decrease hypertensive urgency, prompt treatment with oral antihypertensive medications, such as labetalol, is recommended with the goal of lowering blood pressure gradually over 24-48 hours, as stated in the 2024 ESC guidelines 1. The goal is to achieve a 20-25% reduction in blood pressure in the first few hours, while avoiding rapid blood pressure reduction that can lead to organ hypoperfusion.
Key Considerations
- Patients with acute intracerebral haemorrhage should not undergo immediate BP lowering if systolic BP is <220 mmHg, but careful acute BP lowering with i.v. therapy to <180 mmHg should be considered if systolic BP ≥220 mmHg 1.
- In hypertensive patients with an acute cerebrovascular event, anti-hypertensive treatment is recommended immediately for TIA, or after several days in ischaemic stroke 1.
- Severe hypertension can be treated with i.v. labetalol, oral methyldopa, or nifedipine, with intravenous hydralazine as a second-line option 1.
Medication Options
- Labetalol (200-400 mg orally every 2-3 hours as needed) blocks both alpha and beta receptors, resulting in vasodilation and reduced peripheral resistance.
- Other medications, such as captopril, clonidine, and amlodipine, can also be used, but labetalol is preferred in certain situations, such as hypertensive encephalopathy, as it leaves cerebral blood flow relatively intact for a given BP reduction compared with nitroprusside 1.
Monitoring and Follow-up
- Patients should be monitored closely with frequent blood pressure checks every 30-60 minutes initially.
- After stabilization, transition to a long-term antihypertensive regimen based on comorbidities, and address underlying causes, including medication adherence, substance use, or pain.
From the FDA Drug Label
Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises.
The treatment for hypertensive urgency is sodium nitroprusside (IV), which can immediately reduce blood pressure in hypertensive crises 2.
- The speed of action is immediate, as it is administered intravenously.
- Concomitant longer-acting antihypertensive medication should be administered to minimize the duration of treatment with sodium nitroprusside.
- Captopril (PO) may also be used for hypertension, but its onset of action is not as immediate as sodium nitroprusside, and its dosage must be individualized 3.
From the Research
Treatment of Hypertensive Urgency
- In hypertensive urgency, blood pressure should be lowered gradually over 24 to 48 hours using oral antihypertensives 4.
- The efficacy of available treatments appears similar, but the underlying pathophysiological and clinical findings, mechanism of action, and potential for adverse effects should guide the choice of treatment 4.
- Oral nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine have all been shown to be effective in managing hypertensive urgencies 5.
Speed of Blood Pressure Reduction
- Rapid uncontrolled pressure reduction may be harmful in hypertensive urgency, and blood pressure should be lowered gradually 4.
- In hypertensive emergencies, blood pressure should be immediately reduced to avoid further end-organ damage, with a goal of lowering the mean arterial pressure by 25% over the initial 2 to 4 hours 4.
- Intravenous medications can decrease blood pressure more rapidly than oral medications, but outcomes are similar between the two groups 6.
Choice of Medication
- The choice of medication should be guided by the underlying pathophysiological and clinical findings, mechanism of action, and potential for adverse effects 4.
- Sodium nitroprusside, nitroglycerin, and hydralazine have been used for many years as first-line options for patients with hypertensive emergencies, but newer agents such as nicardipine, fenoldopam, labetalol, and esmolol are increasingly used worldwide 7.
- Clevidipine, a third-generation dihydropyridine calcium-channel blocker, has been shown to reduce mortality compared to nitroprusside in clinical trials 7.