What is the treatment for a 65-year-old female presenting with severe hypertension (blood pressure 215/101) in the Emergency Department (ED)?

From the Guidelines

The immediate treatment for a 65-year-old female with severe hypertension (215/101) in the ED requires prompt but controlled blood pressure reduction to prevent end-organ damage, with intravenous labetalol or nicardipine infusion being the preferred initial management options, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.

Key Considerations

• The goal is to reduce blood pressure by no more than 25% in the first hour, then to 160/100-110 mmHg over the next 2-6 hours, to prevent cerebral hypoperfusion and other complications.
• Concurrent assessment for hypertensive emergency with end-organ damage is essential, including evaluation for stroke, myocardial infarction, acute kidney injury, or hypertensive encephalopathy.
• The choice of treatment, target BP, and timeframe for BP reduction depend on the type of target organ damage, as outlined in the esc council on hypertension position document on the management of hypertensive emergencies 1.

Treatment Options

• Intravenous labetalol 10-20 mg over 2 minutes, which can be repeated or doubled every 10 minutes up to 300 mg total.
• Nicardipine infusion starting at 5 mg/hour and titrating by 2.5 mg/hour every 5-15 minutes up to 15 mg/hour.
• Clevidipine (1-2 mg/hour, titrated by doubling every 90 seconds) is another effective option.

Transition to Oral Medications

• Once stabilized, transition to oral medications like amlodipine 5-10 mg daily, lisinopril 10-20 mg daily, or metoprolol 25-100 mg twice daily should be initiated, as recommended by 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.

From the FDA Drug Label

In other settings (e.g., patients with severe or postoperative hypertension), nicardipine hydrochloride injection (5 to 15 mg/hr) produced dose-dependent decreases in blood pressure. The mean time to therapeutic response for severe hypertension, defined as diastolic blood pressure less than or equal to 95 mmHg or greater or equal to 25 mmHg decrease and systolic blood pressure less than or equal to 160 mmHg, was 77 ± 5 minutes. The average maintenance dose was 8. 0 mg/hr.

For a 65-year-old female presenting with severe hypertension (blood pressure 215/101) in the Emergency Department (ED), nicardipine hydrochloride injection can be considered as a treatment option. The recommended dose for severe hypertension is between 5 to 15 mg/hr. The goal is to achieve a diastolic blood pressure less than or equal to 95 mmHg or a greater than or equal to 25 mmHg decrease and a systolic blood pressure less than or equal to 160 mmHg. The average maintenance dose is 8.0 mg/hr 2.

• Key considerations:
  • Dose-dependent decreases in blood pressure
  • Therapeutic response time for severe hypertension: 77 ± 5 minutes
  • Average maintenance dose: 8.0 mg/hr
• Main goal: Reduce blood pressure to a safer range while monitoring for potential side effects.

From the Research

Treatment of Severe Hypertension in a 65-year-old Female

• The patient's blood pressure is 215/101, which is considered severe hypertension and requires immediate attention in the Emergency Department (ED) 3, 4.
• According to the study by 3, clevidipine is an effective treatment option for acute severe hypertension, with a rapid onset and short duration of action, making it easily titratable for predictable blood pressure control.
• The ECLIPSE trials 4 compared the safety and efficacy of clevidipine with nitroglycerin, sodium nitroprusside, and nicardipine in the treatment of perioperative acute hypertension in patients undergoing cardiac surgery, and found that clevidipine was more effective in maintaining blood pressure within the prespecified range.

Blood Pressure Targets for Older Adults

• The study by 5 recommends a blood pressure target of <130/80 mm Hg for adults <65 years and <130 mm Hg for adults ≥65 years.
• The study by 6 found that an SBP level <130 mm Hg was associated with longevity in women >65 years of age with low cardiovascular disease and other chronic disease risk.

Treatment Options

• Clevidipine is a potential treatment option for severe hypertension in the ED, given its rapid onset and short duration of action 3, 4.
• Other treatment options may include lifestyle modification, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption, as well as first-line drug therapy with thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers 5.