What is the first-line medication to treat acute hypertension?

From the Guidelines

The first-line medication to treat acute hypertension is intravenous labetalol, as it is a preferred option due to its combined alpha and beta-blocking properties that reduce blood pressure without causing reflex tachycardia, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. When managing acute hypertension, it is crucial to consider the clinical situation and the specific condition of the patient.

• The choice of medication depends on the patient's condition, with labetalol often preferred for its ability to reduce blood pressure without causing reflex tachycardia.
• Other options for treating acute hypertension include nicardipine, clevidipine, or nitroprusside, which are calcium channel blockers that provide smooth, predictable blood pressure reduction.
• For hypertensive urgency where oral medications are appropriate, options include labetalol 200-400mg, amlodipine 5-10mg, or captopril 25mg.
• Treatment should aim to lower blood pressure gradually, not more than 25% reduction in the first hour, to avoid organ hypoperfusion, as stated in the 2024 ESC guidelines 1.
• The underlying cause of hypertension should be identified and addressed while monitoring for complications such as end-organ damage, and patients require close monitoring during treatment with frequent blood pressure checks, as recommended by the 2024 ESC guidelines 1.
• Patients may need ICU admission for severe cases requiring continuous IV medications, and the recommended timing and magnitude of BP lowering required for safe BP reduction should be determined based on the affected target organ(s) and whether they require any specific interventions other than BP lowering, as stated in the 2024 ESC guidelines 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. The first-line medication to treat acute hypertension is sodium nitroprusside (IV), as it is indicated for the immediate reduction of blood pressure in hypertensive crises 2.

• It is used for the immediate reduction of blood pressure
• Concomitant longer-acting antihypertensive medication should be administered to minimize the duration of treatment with sodium nitroprusside

From the Research

First-Line Medication for Acute Hypertension

The first-line medication to treat acute hypertension depends on the presence of end-organ damage and the severity of the condition.

• For hypertensive emergencies, which are characterized by acute end-organ damage, immediate reduction in blood pressure is required with a titratable, short-acting, intravenous antihypertensive agent 3.
• Rapid-acting intravenous antihypertensive agents available for this purpose include labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside, although sodium nitroprusside is considered extremely toxic and its use should be avoided 3.
• For hypertensive urgencies, which are characterized by severe hypertension without acute end-organ damage, oral antihypertensive agents are usually sufficient 3, 4.
• Oral agents that have been shown to be effective in managing hypertensive urgencies include nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 4.

Specific Medications

• Esmolol is effective in controlling both supraventricular tachyarrhythmias and severe hypertension, but its use should be avoided in patients with low cardiac output due to its negative inotropic effect 4.
• Nicardipine is a potent arteriolar vasodilator without a significant direct depressant effect on the myocardium, but it should not be used in patients with severe aortic stenosis 4.
• Fenoldopam, a selective post-synaptic dopaminergic receptor (DA1) agonist, has been shown to be effective in treating severe hypertension with a lower incidence of side effects than sodium nitroprusside 4.
• Nitroglycerin ointment may be a possible treatment choice for acute hypertension in hospitalized inpatients, particularly when intravenous medications are not feasible or oral medications cannot be taken 5.