From the Guidelines
The initial treatment for a hypertensive emergency is immediate blood pressure reduction with intravenous antihypertensive medications, with labetalol being a preferred first-line medication in many cases, as seen in the 2019 European Heart Journal study 1. The goal of treatment is to reduce mean arterial pressure by no more than 25% within the first hour, then to a safe target blood pressure within the next 2-6 hours, and then to normal over the next 24-48 hours. Some key points to consider when treating hypertensive emergencies include:
- The choice of antihypertensive medication should be based on the patient's clinical presentation and comorbidities, as outlined in the 2018 Circulation study 1 and the 2018 Journal of the American College of Cardiology study 1.
- Continuous cardiac monitoring, frequent blood pressure checks, and assessment of end-organ damage are essential to ensure safe and effective treatment.
- The underlying cause of the hypertensive emergency should be identified and treated simultaneously, as this can impact the choice of antihypertensive medication and the overall treatment plan.
- After stabilization, transition to oral antihypertensives should be initiated for long-term management, with the goal of preventing future hypertensive emergencies and reducing the risk of cardiovascular complications. Some specific treatment options for different clinical presentations include:
- Labetalol (20-80 mg IV bolus every 10 minutes or 0.5-2 mg/min infusion) for patients with hypertensive encephalopathy, acute ischemic stroke, or acute coronary syndromes.
- Nicardipine (5-15 mg/hr infusion) for patients with acute aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma with hypertensive crisis.
- Sodium nitroprusside (0.25-10 mcg/kg/min) for patients with severe hypertension who require rapid blood pressure reduction, but this should be used with caution due to the risk of cyanide toxicity. It's worth noting that the 2019 European Heart Journal study 1 provides the most recent and highest quality evidence for the treatment of hypertensive emergencies, and should be prioritized when making treatment decisions.
From the FDA Drug Label
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. For more rapid blood pressure reduction, titrate every 5 minutes. In a clinical pharmacologic study in severe hypertensives, an initial 0. 25 mg/kg injection of labetalol HCl, administered to patients in the supine position, decreased blood pressure by an average of 11/7 mmHg.
The initial treatment for a hypertensive emergency involves administering medications such as nicardipine or labetalol via intravenous infusion.
- Nicardipine is initiated at a rate of 5 mg/hr and can be increased by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr.
- Labetalol can be administered as an initial dose of 0.25 mg/kg, with additional doses given as needed to achieve the desired blood pressure reduction. It is essential to closely monitor the patient's blood pressure and adjust the infusion rate accordingly to avoid hypotension or tachycardia 2 3.
From the Research
Initial Treatment for Hypertensive Emergency
The initial treatment for a hypertensive emergency typically involves the use of intravenous antihypertensive agents to rapidly lower blood pressure and prevent further organ damage. Some of the commonly used agents include:
- Sodium nitroprusside
- Nitroglycerin
- Hydralazine
- Nicardipine
- Fenoldopam
- Labetalol
- Esmolol
- Clevidipine 4
Choice of Agent
The choice of agent may depend on the specific clinical scenario and the presence of any underlying medical conditions. For example:
- Nicardipine and labetalol have been shown to be effective and safe in the treatment of hypertensive crises, with nicardipine providing more predictable and consistent blood pressure control 5
- Clevidipine has been shown to reduce mortality compared to nitroprusside in clinical trials 4
Importance of Prompt Treatment
Prompt treatment of hypertensive emergencies is crucial to prevent progression of organ damage and death. The management of these conditions requires close monitoring and titration of antihypertensive agents to achieve a controlled reduction in blood pressure 6
Comparison with Hypertensive Urgencies
Hypertensive urgencies, on the other hand, can often be treated with oral antihypertensive agents, and the goal is to reduce blood pressure to baseline or normal over a period of 24-48 hours 6, 7
Recent Developments
Recent studies have proposed a symptoms- and evidence-based approach to the management of hypertensive emergencies, including the use of a novel algorithm for quick identification of hypertensive emergencies and associated acute organ damage 8