From the Guidelines
The goal blood pressure in a hypertensive emergency varies depending on the clinical presentation, but generally, it involves reducing the mean arterial pressure (MAP) by 20-25% within the first hour, with specific targets for different conditions, such as malignant hypertension, hypertensive encephalopathy, and acute ischemic stroke 1.
Key Considerations
- The specific target blood pressure and timeline for reduction depend on the type of hypertensive emergency and the organs involved, as outlined in the 2020 international society of hypertension global hypertension practice guidelines 1.
- For example, in cases of malignant hypertension with or without thrombotic microangiopathy (TMA) or acute renal failure, the goal is to reduce MAP by 20-25% over several hours 1.
- In contrast, for acute ischemic stroke with indication for thrombolytic therapy, the goal is to reduce MAP by 15% within 1 hour 1.
Treatment Approach
- Immediate treatment typically involves intravenous medications, such as labetalol, nicardipine, clevidipine, or nitroprusside, in a monitored setting like an intensive care unit 1.
- The choice of medication and target blood pressure should be individualized based on the patient's underlying conditions and the target organs affected.
- Continuous blood pressure monitoring is essential to ensure the reduction occurs at an appropriate rate and to avoid organ damage due to hypoperfusion.
Underlying Cause
- Addressing the underlying cause of the hypertensive emergency is crucial for long-term management, and may involve diagnostic workup to confirm or exclude secondary forms of hypertension 1.
From the Research
Goal Blood Pressure in Hypertensive Emergency
- The goal blood pressure in a hypertensive emergency is not explicitly defined as a specific value, but rather as a reduction in mean arterial pressure of approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours 2.
- For aortic dissection, the systolic BP target is lower than 120 mm Hg, to be achieved during the first 20 minutes using a beta-blocker and a vasodilator 2.
- Most authors suggest that hypoperfusion can result if the BP is lowered too suddenly or too far (eg, into the range of <140/90 mm Hg) 2.
- The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, with the appropriate therapeutic approach depending on the patient's clinical presentation 3, 4.
Treatment Approach
- Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents 3, 4, 5.
- Rapid-acting intravenous antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside 3, 4, 5.
- Newer agents, such as clevidipine, may hold considerable advantages over other available agents in the management of hypertensive crises 3, 4.
- Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 3, 4, 5.