From the Guidelines
For a hypertensive emergency with sinus bradycardia and a heart rate of 48 beats per minute, the recommended antihypertensive drips include nicardipine, clevidipine, and nitroprusside, as they effectively lower blood pressure without further depressing heart rate, according to 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.
Key Medications
- Nicardipine: initial dose 5 mg/hr, titrated by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr, with minimal negative chronotropic effects 1.
- Clevidipine: starting at 1-2 mg/hr, titrated by doubling the dose every 90 seconds initially, maximum 32 mg/hr, providing rapid titration with minimal heart rate effects 1.
- Nitroprusside: 0.3-10 mcg/kg/min, offering potent, rapid blood pressure reduction without significant bradycardic effects, but requiring careful monitoring due to the risk of cyanide toxicity 1.
Important Considerations
- Beta-blockers (labetalol, esmolol, metoprolol) should be avoided as they can worsen bradycardia 1.
- Diltiazem and verapamil should not be used due to their negative chronotropic effects.
- Continuous cardiac monitoring and frequent blood pressure checks every 5-15 minutes during initial titration are essential.
- The goal is to reduce mean arterial pressure by no more than 25% in the first hour, then gradually to normal over 24-48 hours to prevent organ hypoperfusion.
Administration and Monitoring
- When administering these medications, it is crucial to monitor for potential side effects and adjust the dose accordingly.
- The choice of medication should be based on the individual patient's condition, including the presence of any comorbidities or contraindications, as outlined in the guidelines 1.
From the FDA Drug Label
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. For more rapid blood pressure reduction, titrate every 5 minutes.
The recommended antihypertensive drip for hypertensive emergency with sinus bradycardia and a heart rate of 48 beats per minute is nicardipine (IV), initiated at a rate of 5 mg/hr and titrated as needed to achieve desired blood pressure reduction, with a maximum rate of 15 mg/hr 2.
- Key considerations:
- Monitor closely when titrating nicardipine hydrochloride injection in patients with impaired cardiac function.
- Discontinue infusion in case of hypotension or tachycardia, and restart at a lower dose when blood pressure and heart rate stabilize.
From the Research
Antihypertensive Drips for HTN Emergency with Sinus Bradycardia
- For hypertensive emergencies with sinus bradycardia and a heart rate of 48 beats per minute, several antihypertensive drips can be considered.
- Agents such as sodium nitroprusside, nitroglycerin, and hydralazine have been used for many years as first-line options, although their potential adverse effects and difficulties in use are well known 3.
- Newer and safer agents, including nicardipine, fenoldopam, labetalol, and esmolol, are increasingly used worldwide 3.
- Clevidipine, a third-generation dihydropyridine calcium-channel blocker, has been shown to reduce mortality when compared with nitroprusside and is a viable option for blood pressure control in hypertensive crises 3, 4, 5.
- A study comparing nicardipine and clevidipine for blood pressure control in hypertensive crisis found that nicardipine achieved a systolic blood pressure goal of <160 mm Hg at 2-6 h significantly more often than the clevidipine group 4.
- Another study found that clevidipine was effective in lowering blood pressure in adults with acute severe hypertension, with a rapid onset and short duration of action, making it easily titratable for predictable blood pressure control 5.
- In a neuroscience intensive care population, clevidipine and nicardipine were found to have similar efficacy in achieving target systolic blood pressure goals, although clevidipine resulted in significantly less volume administered per patient 6.
Recommended Antihypertensive Drips
- Nicardipine
- Clevidipine
- Esmolol: a beta-blocker that can be used to control heart rate and blood pressure in hypertensive emergencies, particularly in patients with sinus bradycardia 3.
- Labetalol: a mixed alpha- and beta-blocker that can be used to control blood pressure in hypertensive emergencies, although its use may be limited in patients with sinus bradycardia due to its potential to worsen bradycardia 3.