What is the treatment for a hypertensive emergency?

From the Guidelines

The treatment for a hypertensive emergency requires immediate blood pressure reduction with intravenous medications in an intensive care setting, with first-line medications including labetalol, nicardipine, or clevidipine, as recommended by 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 160/100-110 mmHg within the next 2-6 hours, and finally to normal levels over the next 24-48 hours.

• The choice of medication depends on the specific clinical presentation and the presence of comorbidities, as outlined in the 2019 European Heart Journal study 1.
• For example, labetalol may be preferred in patients with hypertensive encephalopathy, as it leaves cerebral blood flow relatively intact for a given BP reduction compared with nitroprusside, and does not increase intracranial pressure.
• Concurrent management of the specific organ damage, such as neurologic, cardiac, or renal complications, is essential, as emphasized in the 2018 Circulation study 1.
• After stabilization, patients should transition to oral antihypertensive medications and undergo evaluation for secondary causes of hypertension, with close follow-up necessary to ensure long-term blood pressure control and prevent recurrence of hypertensive crises, as recommended by the 2018 Journal of the American College of Cardiology study 1.

From the FDA Drug Label

Nicardipine hydrochloride injection is indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable. 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.

The treatment for a hypertensive emergency involves administering nicardipine hydrochloride injection by slow continuous infusion.

• The initial infusion rate is 5 mg/hr, which can be increased by 2.5 mg/hr every 15 minutes as needed, up to a maximum of 15 mg/hr.
• The goal is to achieve a gradual reduction in blood pressure, and the infusion rate should be adjusted accordingly to maintain the desired response 2.
• It is essential to monitor the patient closely, especially when titrating the infusion rate, to avoid hypotension or tachycardia 2.

From the Research

Definition and Classification of Hypertensive Emergency

• A hypertensive emergency is a condition characterized by a severe elevation of blood pressure, typically greater than 180/120 mmHg, with evidence of acute end-organ damage 3, 4, 5.
• Hypertensive emergencies are distinguished from hypertensive urgencies, which are characterized by a severe elevation of blood pressure without evidence of acute end-organ damage 3, 4, 6.

Treatment of Hypertensive Emergency

• The primary goal of treatment in a hypertensive emergency is to safely reduce blood pressure and prevent further end-organ damage 3, 4, 7.
• Treatment typically involves the use of short-acting, intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 3, 7, 6.
• The choice of agent depends on the type of end-organ damage, pharmacokinetics, and comorbidities 7, 5.
• Sodium nitroprusside, although effective, is associated with significant toxicity and should be avoided if possible 3, 7.
• Hospitalization in an intensive care unit is usually required for patients with hypertensive emergencies, where close monitoring and titration of antihypertensive therapy can be performed 3, 4.

Comparison of Treatment Options

• Newer agents, such as clevidipine and fenoldopam, may offer advantages over traditional agents, including improved safety and efficacy profiles 3, 7.
• The use of oral antihypertensive agents is generally not recommended for the treatment of hypertensive emergencies, as they may not provide adequate or rapid control of blood pressure 3, 4.
• Agents such as nifedipine, nitroglycerin, and hydralazine are not recommended as first-line therapies due to their potential for adverse effects and toxicity 3, 6.