From the Guidelines
A hypertensive crisis requires immediate medical attention in an emergency setting, with treatment typically involving intravenous antihypertensive medications to rapidly lower blood pressure in a controlled manner. The goal is to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and then gradually to normal levels over the following 24-48 hours 1.
Key Considerations
- First-line medications include labetalol, nicardipine, or clevidipine, with sodium nitroprusside used cautiously due to cyanide toxicity risk 1.
- The choice of antihypertensive treatment is predominantly determined by the type of organ damage, with specific clinical presentations of hypertensive emergencies including malignant hypertension, hypertensive encephalopathy, and hypertensive thrombotic microangiopathy 1.
- Patients with substantially elevated BP who lack acute hypertension-mediated end organ damage do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation 1.
Treatment Approach
- Intravenous therapy is usually required for hypertensive emergencies, with the therapeutic goal being to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment 1.
- Compelling conditions requiring rapid lowering of SBP, usually to <140 mm Hg, in the first hour of treatment include aortic dissection, severe preeclampsia or eclampsia, and pheochromocytoma with hypertensive crisis 1.
- Once stabilized, patients need evaluation for underlying causes, transition to oral medications, and a long-term management plan 1.
Important Medications
- Labetalol (initial dose 20mg IV, followed by 20-80mg every 10 minutes as needed) 1
- Nicardipine (initial rate 5mg/hour, increased by 2.5mg/hour every 5-15 minutes, maximum 15mg/hour) 1
- Clevidipine (1-2mg/hour initially, doubled every 90 seconds as needed) 1
- Sodium nitroprusside (0.3-10 mcg/kg/minute) 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. Concomitant longer-acting antihypertensive medication should be administered so that the duration of treatment with sodium nitroprusside can be minimized.
The treatment for a hypertensive crisis is sodium nitroprusside (IV), which is indicated for the immediate reduction of blood pressure in adult and pediatric patients in hypertensive crises.
- It is recommended to administer concomitant longer-acting antihypertensive medication to minimize the duration of treatment with sodium nitroprusside.
- Another option is clevidipine (IV), which can be used to reduce blood pressure, but the primary indication from the provided labels for hypertensive crisis is sodium nitroprusside 2.
From the Research
Treatment of Hypertensive Crisis
The treatment of a hypertensive crisis depends on the severity of the condition and the presence of end-organ damage.
- Hypertensive emergencies, which are characterized by acute end-organ damage, require immediate reduction in blood pressure with a titratable short-acting intravenous antihypertensive agent 3, 4, 5.
- Hypertensive urgencies, which are characterized by severe hypertension without acute end-organ damage, can be treated with oral antihypertensive agents 3, 4, 5.
Medications Used in Treatment
Several medications are available for the treatment of hypertensive crises, including:
- Rapid-acting intravenous antihypertensive agents such as labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 3, 4, 6, 5.
- Oral antihypertensive agents for the treatment of hypertensive urgencies 3, 4, 5.
- Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided due to their potential adverse effects 3, 4, 5.
- Sodium nitroprusside should be used with caution due to its toxicity 3, 4, 6, 5.