What are the first-line medications for emergent blood pressure reduction in the Emergency Room (ER) for hypertensive emergencies?

From the Guidelines

For hypertensive emergencies in the ER, first-line medications include intravenous labetalol, nicardipine, clevidipine, and nitroprusside, with the choice of medication depending on the specific emergency and the patient's comorbidities, as recommended by the most recent guidelines 1. The goal of treatment is to reduce mean arterial pressure by no more than 25% within the first hour, then gradually to 160/100-110 mmHg over the next 2-6 hours, while minimizing target organ damage.

• Labetalol is typically administered as 20-80 mg IV boluses every 10 minutes or as a continuous infusion at 0.5-2 mg/min.
• Nicardipine is given as a continuous infusion starting at 5 mg/hr, titrated up by 2.5 mg/hr every 5-15 minutes to a maximum of 15 mg/hr.
• Clevidipine begins at 1-2 mg/hr and can be titrated up to 21 mg/hr.
• Sodium nitroprusside is dosed at 0.3-10 mcg/kg/min but requires careful monitoring due to cyanide toxicity risk with prolonged use. Medication choice depends on the specific emergency, with labetalol and nicardipine preferred for most situations due to their predictable effects and safety profiles, as supported by recent guidelines 1. Some key considerations for specific emergencies include:
• Acute aortic dissection: esmolol and labetalol are preferred, with a goal of reducing systolic blood pressure to ≤120 mmHg within 20 minutes 1.
• Acute pulmonary edema: clevidipine, nitroglycerin, and nitroprusside are preferred, with beta blockers contraindicated 1.
• Acute coronary syndromes: esmolol, labetalol, nicardipine, and nitroglycerin are preferred, with nitrates given in the presence of PDE-5 inhibitors potentially inducing profound hypotension 1. Continuous cardiac monitoring, frequent blood pressure checks, and assessment of end-organ damage are essential during treatment, as emphasized by the guidelines 1.

From the FDA Drug Label

Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. Labetalol beta1-receptor blockade in man was demonstrated by a small decrease in the resting heart rate, attenuation of tachycardia produced by isoproterenol or exercise, and by attenuation of the reflex tachycardia to the hypotension produced by amyl nitrite. Labetalol produces dose-related falls in blood pressure without reflex tachycardia and without significant reduction in heart rate, presumably through a mixture of its alpha-blocking and beta-blocking effects.

The first-line medications for emergent blood pressure reduction in the Emergency Room (ER) for hypertensive emergencies are:

• Sodium nitroprusside (IV): indicated for the immediate reduction of blood pressure in hypertensive crises 2
• Labetalol (IV): produces dose-related falls in blood pressure without reflex tachycardia and is used for urgent blood pressure reduction 3

From the Research

Emergent Blood Pressure Medication Administration in the ER

The first-line medications for emergent blood pressure reduction in the Emergency Room (ER) for hypertensive emergencies include:

• Sodium nitroprusside, administered in an intensive care unit 4, 5
• Nicardipine, a dihydropyridine calcium antagonist, which produces significant antihypertensive effects and is effective and safe in the management of severe hypertension and hypertensive crises 6, 5
• Labetalol, which has been used parenterally for rapid control of severe hypertension 6, 5
• Hydralazine, which has been used for many years as a first-line option for patients with hypertensive emergencies 5
• Clevidipine, a third-generation dihydropyridine calcium-channel blocker, which has been shown in clinical trials to reduce mortality when compared with nitroprusside 5
• Esmolol, which is increasingly used worldwide for the treatment of patients with hypertensive emergencies 5
• Fenoldopam, which is also used for the treatment of patients with hypertensive emergencies 5
• Nitroglycerin, which has been used for many years as a first-line option for patients with hypertensive emergencies 5

Key Considerations

When administering these medications, it is essential to consider the following:

• The goal of treatment is to reduce blood pressure by about 10% during the first hour and another 15% gradually over the next 2 to 3 hours to prevent cerebral hypoperfusion 4
• The exception to this management strategy is aortic dissection, for which the target is systolic blood pressure <120 mm Hg after 20 minutes 4
• Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy 4
• The patient's clinical status should be evaluated, noting particularly cardiac, neurologic, and renal functions 6
• The choice of treatment should be based on speed and efficacy of action and on hemodynamic, vascular, and renal consequences 6