What are the treatment options for acute hypertension?

From the Guidelines

Acute hypertension should be treated promptly with intravenous antihypertensive drugs, such as esmolol, labetalol, or clevidipine, to minimize target organ damage and reduce systolic blood pressure to <140 mm Hg in the first hour of treatment, especially in patients with compelling conditions like aortic dissection, severe preeclampsia or eclampsia, and pheochromocytoma with hypertensive crisis. The choice of antihypertensive drug depends on the presence of comorbidities, such as acute aortic dissection, acute pulmonary edema, or acute coronary syndromes, 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 example, in patients with acute aortic dissection, esmolol or labetalol are preferred, while in patients with acute pulmonary edema, clevidipine, nitroglycerin, or nitroprusside are recommended, with beta blockers being contraindicated 1. It is essential to continuously monitor patients and adjust treatment accordingly to prevent complications like stroke, myocardial infarction, or renal failure. The underlying cause of hypertension should be identified and addressed, and patients should transition to long-term antihypertensive therapy with appropriate follow-up to prevent recurrence. Key considerations include:

• Rapid recognition of the problem and early initiation of appropriate antihypertensive treatment
• Minimizing target organ damage by reducing systolic blood pressure to <140 mm Hg in the first hour of treatment
• Choosing the appropriate antihypertensive drug based on comorbidities and compelling conditions
• Continuous monitoring and adjustment of treatment to prevent complications
• Identifying and addressing the underlying cause of hypertension
• Transitioning to long-term antihypertensive therapy with appropriate follow-up 1.

From the FDA Drug Label

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 When treating acute hypertensive episodes in patients with chronic hypertension, discontinuation of infusion is followed by a 50% offset of action in 30 minutes ± 7 minutes but plasma levels of drug and gradually decreasing antihypertensive effects exist for many hours. Titration 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.

Treatment for Acute Hypertension:

• Nicardipine (IV): Administer by slow continuous infusion at a concentration of 0.1 mg/mL, starting at 5 mg/hr and titrating up to 15 mg/hr as needed.
• Labetalol (IV): Initial dose of 0.25 mg/kg, followed by additional doses of 0.5 mg/kg at 15-minute intervals, up to a total cumulative dose of 1.75 mg/kg, or an initial dose of 20 mg followed by 40 or 80 mg at 10-minute intervals.
• Nitroglycerin (IV): Indicated for treatment of peri-operative hypertension, but specific dosing information is not provided in the label.

2, 3, 4

From the Research

Treatment Approaches for Acute Hypertension

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, with the appropriate therapeutic approach depending on the patient's clinical presentation 5, 6.
• Hypertensive emergencies, characterized by acute end-organ damage, require immediate reduction in blood pressure with titratable, short-acting, intravenous antihypertensive agents in an intensive care unit setting 5, 6, 7.
• Hypertensive urgencies, defined as severe hypertension without acute end-organ damage, can usually be treated with oral antihypertensive agents 5, 6.

Intravenous Antihypertensive Agents

• Rapid-acting intravenous antihypertensive agents available for the treatment of hypertensive emergencies include labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside 5, 6, 7.
• Newer agents, such as clevidipine, may offer advantages over traditional agents due to their unique pharmacodynamic and pharmacokinetic properties 8.
• Sodium nitroprusside, although effective, is an extremely toxic drug and its use should be avoided or approached with caution due to its potential adverse effects 5, 6, 8.

Selection of Antihypertensive Agents

• The selection of a specific intravenous antihypertensive agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 7.
• Agents like hydralazine, immediate release nifedipine, and nitroglycerin should be avoided as first-line therapies due to their associated toxicities and adverse effects 5, 6.
• The role of certain agents, such as intravenous labetalol and nicardipine, may be limited to specific situations, such as perioperative hypertension and subarachnoid hemorrhage 9.