How should a patient with severe hypertension be managed?

From the Guidelines

The nurse should immediately assess the patient's blood pressure and medical history to determine the best course of action, and consider referring the patient to a specialist center if they have resistant hypertension, as defined by a seated office BP >140/90 mm Hg despite being managed with three or more antihypertensive medications at optimal doses, including a diuretic 1. The patient's blood pressure should be carefully measured to confirm the diagnosis of severe hypertension, and the nurse should exclude causes of pseudoresistance, such as poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy 1. Some key considerations for managing the patient's condition include:

• Optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, with maximally tolerated doses of diuretics and optimal choice of diuretic 1
• Adding a low dose of spironolactone as the 4th line agent in those whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets, or using alternative medications such as amiloride, doxazosin, eplerenone, clonidine, and beta-blockers if spironolactone is contraindicated or not tolerated 1
• Considering screening patients for secondary causes of hypertension as appropriate, and referring them to a specialist center if necessary 1. The goal of treatment is to reduce the patient's blood pressure to a safe range, prevent end-organ damage, and improve their quality of life, while also minimizing the risk of adverse effects from treatment 1.

From the FDA Drug Label

The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. 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. 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 nurse should initiate therapy with either nicardipine or labetalol to manage the patient's severe hypertension.

• For nicardipine, start with a rate of 5 mg/hr and adjust as needed to achieve the desired blood pressure reduction, up to a maximum of 15 mg/hr.
• For labetalol, an initial dose of 0.25 mg/kg can be administered, with additional doses given as needed to achieve the desired effect. It is essential to monitor the patient's blood pressure and adjust the infusion rate accordingly to avoid hypotension or tachycardia 2 3.

From the Research

Management of Severe Hypertension

The management of severe hypertension requires immediate attention to prevent end-organ damage. The following steps can be taken:

• Assess the patient's blood pressure and overall condition to determine the severity of the hypertension
• Administer intravenous antihypertensive agents, such as labetalol or nicardipine, as needed to lower the blood pressure 4, 5, 6, 7, 8
• Monitor the patient's blood pressure and adjust the antihypertensive therapy as needed to achieve the desired blood pressure range

Choice of Antihypertensive Agent

The choice of antihypertensive agent depends on various factors, including the patient's underlying medical conditions and the severity of the hypertension. Studies have compared the efficacy and safety of labetalol and nicardipine in the management of severe hypertension:

• A systematic review found that nicardipine and labetalol have comparable efficacy and safety in the management of hypertensive crises, although nicardipine may provide more predictable and consistent blood pressure control 4
• A randomized controlled trial found that nicardipine was more effective than labetalol in achieving target blood pressure range within 30 minutes in patients with renal dysfunction 5
• A retrospective chart review found that labetalol, nicardipine, and hydralazine had similar effects on time to target blood pressure before thrombolytic therapy in patients with acute ischemic stroke 6
• A retrospective cohort study found that continuous-infusion labetalol and nicardipine had similar safety and efficacy outcomes in the management of hypertension in stroke patients 7
• A study found that continuous-infusion labetalol and nicardipine were comparable in safety and efficacy in controlling blood pressure in patients with acute stroke, although labetalol had a shorter time to goal blood pressure 8

Monitoring and Adjustment of Therapy

It is essential to monitor the patient's blood pressure and adjust the antihypertensive therapy as needed to achieve the desired blood pressure range:

• Monitor the patient's blood pressure regularly to assess the effectiveness of the antihypertensive therapy
• Adjust the dose or type of antihypertensive agent as needed to achieve the desired blood pressure range
• Be aware of potential side effects of antihypertensive agents, such as hypotension, tachycardia, or bradycardia, and adjust the therapy accordingly 5, 7, 8