What medication reduces mortality in hypertensive emergency?

From the Guidelines

The primary medication that reduces mortality in hypertensive emergency is intravenous (IV) labetalol, due to its ability to combine alpha and beta-blocking effects, making it an ideal choice for managing hypertensive emergencies 1. For immediate management:

• Labetalol: Start with 20 mg IV bolus, followed by 20-80 mg boluses every 10 minutes or 1-2 mg/min infusion.
• Nicardipine: Begin with 5 mg/hr IV infusion, increase by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr.
• Clevidipine: Start at 1-2 mg/hr IV infusion, double the dose every 90 seconds until target BP, maximum 32 mg/hr. The goal is to reduce mean arterial pressure by no more than 25% within the first hour, then gradually to 160/100-110 mmHg within the next 2-6 hours. These medications work quickly to lower blood pressure and reduce the risk of organ damage. Key considerations for management include:
• The type of hypertensive organ damage, such as stroke, acute hypertensive microangiopathy, and encephalopathy, cardiogenic pulmonary oedema, coronary ischaemia, and acute aortic disease.
• The need for rapid BP lowering in patients with pulmonary oedema and acute aortic dissection.
• The importance of close haemodynamic monitoring in a clinical area.
• The potential for differences in preference and experience with regard to the use of intravenous BP-lowering medication. It's crucial to monitor the patient closely, adjusting dosage based on blood pressure response and watching for signs of organ dysfunction, as recommended by the European Heart Journal 1. Once stabilized, transition to oral medications for long-term management, taking into account the patient's individual needs and response to treatment, as outlined in the Journal of the American College of Cardiology 1.

From the FDA Drug Label

Although beta-blockers should be avoided in overt congestive heart failure, if necessary, labetalol can be used with caution in patients with a history of heart failure who are well compensated. Rapid Decreases of Blood Pressure Caution must be observed when reducing severely elevated blood pressure A number of adverse reactions, including cerebral infarction, optic nerve infarction, angina, and ischemic changes in the electrocardiogram, have been reported with other agents when severely elevated blood pressure was reduced over time courses of several hours to as long as 1 or 2 days The desired blood pressure lowering should therefore be achieved over as long a period of time as is compatible with the patient's status. Intravenous labetalol has been shown to be effective in lowering the blood pressure and relieving symptoms in patients with pheochromocytoma; higher than usual doses may be required.

The medication that reduces mortality in hypertensive emergency is not explicitly stated in the provided drug labels. However, labetalol (IV) can be used to lower blood pressure in hypertensive emergencies, including pheochromocytoma, with caution 2.

• Key considerations:
  • Caution must be observed when reducing severely elevated blood pressure.
  • The desired blood pressure lowering should be achieved over a period of time compatible with the patient's status.
  • Labetalol can be effective in lowering blood pressure and relieving symptoms in patients with pheochromocytoma. However, the provided information does not directly support the claim that labetalol reduces mortality in hypertensive emergency.

From the Research

Medications for Hypertensive Emergency

The following medications are used to reduce mortality in hypertensive emergency:

• Nicardipine 3, 4, 5
• Nitroprusside 3, 4
• Fenoldopam 3, 4
• Nitroglycerin 3, 4
• Enalaprilat 3, 4
• Hydralazine 3, 4
• Labetalol 3, 4, 5
• Esmolol 3, 4
• Phentolamine 3
• Clevidipine 3

Selection of Medication

The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 3, 4.

Patient Characteristics and Response to Medication

Patient characteristics such as male gender and history of previous stroke are associated with difficult to control blood pressure 5.

Treatment Goals

The treatment goal is to quickly lower blood pressure with intravenous medications to minimize end-organ damage in patients with hypertensive emergency 5, 6.

Common Presentations and Treatment Options

Hypertensive emergencies typically present with a blood pressure greater than 180/120 mmHg leading to end-organ damage, and therapeutic intervention should be a short-acting, easily titratable, intravenous antihypertensive medication based on the type of end-organ damage, pharmacokinetics, and comorbidities 6.