What is the treatment for hypertensive emergency in a hospital setting?

Treatment of Hypertensive Emergency in Hospital Setting

In a hypertensive emergency, patients should be admitted to an intensive care unit for immediate BP reduction using intravenous medications, with the treatment approach tailored to the specific type of organ damage present. 1

Definition and Diagnosis

Hypertensive emergency is characterized by:

• Severe BP elevation (>180/120 mmHg) with evidence of acute target organ damage 1
• Target organ damage may include hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, pulmonary edema, aortic dissection, or eclampsia 1

General Treatment Principles

1. Setting: Admit to ICU for continuous BP monitoring and parenteral medication administration 1

2. BP Reduction Goals:

   • Initial reduction: No more than 25% of mean arterial pressure within first hour 1
   • Secondary target: 160/100-110 mmHg within next 2-6 hours 1
   • Final target: Gradual normalization over 24-48 hours if stable 1

3. Caution: Avoid excessive BP reduction which can precipitate renal, cerebral, or coronary ischemia 1

First-Line Medications by Specific Condition

Clinical Presentation	Target BP	First-Line Treatment	Alternatives
Malignant hypertension/encephalopathy	MAP -20% to -25%	Labetalol	Nitroprusside, Nicardipine
Acute ischemic stroke (BP >220/120)	MAP -15%	Labetalol	Nitroprusside, Nicardipine
Acute hemorrhagic stroke	SBP 130-180 mmHg	Labetalol	Nicardipine, Urapidil
Acute coronary event	SBP <140 mmHg	Nitroglycerin	Labetalol, Urapidil
Acute pulmonary edema	SBP <140 mmHg	Nitroprusside or Nitroglycerin with loop diuretic	Urapidil with loop diuretic
Acute aortic dissection	SBP <120 mmHg, HR <60	Esmolol + Nitroprusside/Nitroglycerin	Labetalol, Nicardipine
Eclampsia	SBP <160 mmHg, DBP <105 mmHg	Labetalol or Nicardipine + Magnesium sulfate	-

1, 2

Key Parenteral Medications

1. Sodium Nitroprusside

   • Dosage: 0.25-10 μg/kg/min IV infusion
   • Onset: Immediate
   • Duration: 1-2 minutes
   • Caution: Risk of cyanide toxicity with prolonged use; avoid in high intracranial pressure or azotemia 1

2. Nicardipine

   • Dosage: 5-15 mg/h IV
   • Onset: 5-10 minutes
   • Duration: 15-30 minutes, may exceed 4 hours
   • Administration: Start at 5 mg/hr, increase by 2.5 mg/hr every 15 minutes up to 15 mg/hr 3
   • Caution: Avoid in acute heart failure; use with caution in coronary ischemia 1

3. Labetalol

   • Dosage: 20-80 mg IV bolus every 10 minutes
   • Onset: 5-10 minutes
   • Duration: 3-6 hours
   • Widely available and recommended as essential in hospital formularies 1

Special Considerations

1. Aortic Dissection: Requires immediate reduction of SBP to <120 mmHg and heart rate <60 bpm using beta-blockers (esmolol) plus vasodilators 1

2. Ischemic Stroke: Generally withhold BP-lowering medication unless BP >220/120 mmHg or thrombolytic therapy is planned 1

3. Transition to Oral Therapy: Can usually be instituted after 6-12 hours of parenteral therapy 4

Common Pitfalls to Avoid

1. Avoid short-acting nifedipine for initial treatment of hypertensive emergencies due to risk of precipitous BP drops 1, 5

2. Avoid excessive BP reduction which can lead to organ hypoperfusion and ischemia 1

3. Avoid hydralazine in most hypertensive emergencies (except eclampsia) due to unpredictable response and prolonged duration of action 6

4. Don't confuse hypertensive urgency with emergency - urgencies (severe BP elevation without acute organ damage) can typically be managed with oral medications and don't require ICU admission 5

By following these evidence-based guidelines, mortality from hypertensive emergencies can be significantly reduced through prompt recognition and appropriate management.