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 most recent guidelines 1.

Key Considerations

• The goal 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.
• Rapid, excessive blood pressure reduction must be avoided as it can cause organ hypoperfusion.
• Concurrent management of the specific organ damage is essential, such as administering nitroglycerin for acute coronary syndromes or furosemide for pulmonary edema.

Medication Options

• Labetalol: initial dose 20mg IV, followed by 20-80mg every 10 minutes as needed.
• Nicardipine: initial rate 5mg/hour, increased by 2.5mg/hour every 5-15 minutes, maximum 15mg/hour.
• Clevidipine: 1-2mg/hour initially, doubled every 90 seconds as needed, maximum 32mg/hour.

Specific Clinical Presentations

• Malignant hypertension with or without TMA or acute renal failure: reduce MAP by 20-25% over several hours, with labetalol as the first-line treatment 1.
• Hypertensive encephalopathy: immediate reduction of MAP by 20-25%, with labetalol as the first-line treatment 1.
• Acute ischemic stroke: reduce MAP by 15% over 1 hour, with labetalol as the first-line treatment 1.

Importance of Guidelines

The 2020 International Society of Hypertension global hypertension practice guidelines 1 provide the most recent and comprehensive recommendations for the management of hypertensive emergencies, emphasizing the importance of individualized treatment approaches based on the specific clinical presentation and comorbidities.

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. Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg

The treatment for a hypertensive emergency includes:

• Nicardipine hydrochloride injection: initiate therapy at a rate of 5 mg/hr, increasing by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved 2
• Labetalol HCl: administer as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours 3 Key considerations:
• Monitor blood pressure and heart rate closely during treatment
• Adjust the rate of infusion as needed to maintain desired response
• Be cautious of potential side effects, such as hypotension and tachycardia 2
• Consider the patient's clinical condition and medical history when selecting a treatment option 2

From the Research

Treatment Overview

The treatment for a hypertensive emergency typically involves the use of parenteral drugs and careful intraarterial blood pressure monitoring 4. The goal is to lower the blood pressure quickly and safely to prevent further organ damage.

Medications Used

Some of the medications used to treat hypertensive emergencies include:

• Sodium nitroprusside (SNP), which has reliable antihypertensive activity and is often used in patients undergoing neurovascular surgery 4, 5
• Hydralazine, which is commonly used in the treatment of hypertension in eclampsia and preeclampsia 4
• Nitroglycerin, which is useful in patients prone to myocardial ischemia, but should be avoided in patients with increased intracranial pressure 4
• Esmolol, which is effective in controlling both supraventricular tachyarrhythmias and severe hypertension, but should be avoided in patients with low cardiac output 4
• Nicardipine, which is a potent arteriolar vasodilator without a significant direct depressant effect on the myocardium 4, 5
• Fenoldopam, which is a selective post-synaptic dopaminergic receptor (DA1) agonist that has been shown to be effective in treating severe hypertension with a lower incidence of side effects than SNP 4, 5
• Clevidipine, which is a third-generation dihydropyridine calcium-channel blocker that has been shown to reduce mortality when compared with nitroprusside 5

Treatment Approach

The treatment approach for hypertensive emergencies typically involves:

• Immediate treatment with intravenous antihypertensive medications 6, 7
• Close monitoring of blood pressure and organ function 4, 6
• Selection of medications based on the type of end-organ damage, pharmacokinetics, and comorbidities 7
• Avoidance of certain medications in patients with specific conditions, such as increased intracranial pressure or low cardiac output 4

Hypertensive Urgencies

Hypertensive urgencies, on the other hand, can usually be managed with oral agents, such as:

• Nifedipine, which has a rapid onset of action and can lower blood pressure effectively within the first few hours after dosing 8
• Clonidine, which has a maximal blood pressure lowering effect at 2-4 hours after dosing 8
• Captopril, which has a rapid onset of action and can lower blood pressure effectively within the first few hours after dosing 8
• Labetalol, which has a maximal blood pressure lowering effect at 2-4 hours after dosing 8