What is the treatment for hypertensive encephalopathy?

From the Guidelines

The treatment for hypertensive encephalopathy requires immediate blood pressure reduction in a controlled manner, with labetalol being the preferred initial management option due to its ability to leave cerebral blood flow relatively intact for a given BP reduction compared with nitroprusside, and does not increase intracranial pressure 1.

Key Considerations

• Initial management involves IV antihypertensive medications such as labetalol (20-80 mg IV bolus every 10 minutes or 0.5-2 mg/min infusion), nicardipine (5-15 mg/hr infusion), or sodium nitroprusside (0.25-10 μg/kg/min infusion) 1.
• The goal 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.
• Patients require ICU admission for continuous BP monitoring and neurological assessment.
• Once stabilized, transition to oral antihypertensives should occur, with medications like ACE inhibitors, ARBs, calcium channel blockers, or beta-blockers.
• Addressing the underlying cause of hypertension is essential for long-term management.

Supportive Care

• Controlled BP reduction is critical because rapid decreases can lead to cerebral hypoperfusion and ischemia, as chronic hypertension shifts cerebral autoregulation to higher pressure ranges.
• Supportive care including airway management, seizure control with benzodiazepines if needed, and management of complications is also important for complete treatment.

Alternative Options

• Nitroprusside and nicardipine can alternatively be used for this type of emergency, but labetalol is preferred due to its effects on cerebral blood flow 1.
• The administration of ACE-inhibitors can be used, but must be started at a very low dose to prevent sudden decreases in BP 1.

From the FDA Drug Label

1. 4 Dosage for Initiation of Therapy in a Drug-Free Patient The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. 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 hypertensive encephalopathy with nicardipine (IV) involves initiating therapy at a rate of 5 mg/hr and titrating every 15 minutes by increasing the infusion rate by 2.5 mg/hr up to a maximum of 15 mg/hr until the desired blood pressure reduction is achieved 2.

From the Research

Treatment of Hypertensive Encephalopathy

The treatment of hypertensive encephalopathy involves promptly lowering the blood pressure to prevent further neurological complications. The following are key points to consider:

• The mean arterial pressure should be lowered by 20% to 25% within the first hour of patient presentation, followed by further gradual reduction in blood pressure over the following 24 hours 3.
• Patients diagnosed with hypertensive encephalopathy should be treated promptly to avoid further neurological complications 3, 4.
• The diagnosis of hypertensive encephalopathy should be distinguished from other cerebral complications of severe hypertension by obtaining careful history and performing thorough physical examination 4.
• Potent drugs are available for prompt reduction of blood pressure, and the only definitive criterion for the diagnosis of this syndrome is its prompt response to therapy 4.

Medications Used

The following medications can be used to treat hypertensive encephalopathy:

• Intravenous labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside are commonly used to rapidly lower blood pressure 5, 6.
• Clevidipine is a newer agent that may hold considerable advantages in the management of hypertensive crises 6.
• Hydralazine, immediate release nifedipine, and nitroglycerin should be avoided due to their toxicity and adverse effects 5, 6.
• Sodium nitroprusside should be used with caution because of its toxicity 5, 6.

Management

The management of hypertensive encephalopathy involves:

• Immediate reduction in blood pressure in patients with acute end-organ damage (i.e., hypertensive emergency) using a titratable, short-acting, intravenous antihypertensive agent 5, 6.
• Treatment in an intensive care unit for patients with hypertensive emergencies 5, 6.
• Oral antihypertensive agents for patients with severe hypertension without acute end-organ damage (i.e., hypertensive urgency) 5, 6.