What is the immediate treatment for a patient with hypertension injury?

Immediate Treatment for Hypertensive Injury

For patients with hypertensive emergency (severe BP elevation with evidence of target organ damage), immediate admission to an intensive care unit is recommended for continuous BP monitoring and parenteral administration of appropriate antihypertensive agents. 1

Definition and Classification

Hypertensive emergencies are defined as:

• Severe BP elevations (>180/120 mmHg) WITH evidence of new or worsening target organ damage
• Examples of target organ damage include:
  • Hypertensive encephalopathy
  • Intracerebral hemorrhage
  • Acute ischemic stroke
  • Acute myocardial infarction
  • Acute left ventricular failure with pulmonary edema
  • Unstable angina
  • Dissecting aortic aneurysm
  • Acute renal failure
  • Eclampsia

Treatment Algorithm

Step 1: Assess for Compelling Conditions

• For patients with compelling conditions (aortic dissection, severe preeclampsia/eclampsia, or pheochromocytoma crisis):
  • Reduce SBP to <140 mmHg during the first hour
  • For aortic dissection, further reduce to <120 mmHg 1

Step 2: For Patients Without Compelling Conditions

• Reduce SBP by no more than 25% within the first hour
• Then, if stable, reduce to 160/100 mmHg within the next 2-6 hours
• Cautiously reduce to normal during the following 24-48 hours 1

Step 3: Select Appropriate IV Antihypertensive Agent

First-line IV agents:

1. Nicardipine (calcium channel blocker)

   • Initial dose: 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h
   • Onset: 5-10 minutes, duration: 15-30 minutes (may exceed 4 hours)
   • Contraindicated in advanced aortic stenosis 1, 2

2. Clevidipine (calcium channel blocker)

   • Initial dose: 1-2 mg/h, doubling every 90 seconds until BP approaches target
   • Contraindicated in patients with soybean/egg allergies or lipid metabolism disorders 1

3. Sodium nitroprusside (vasodilator)

   • Initial dose: 0.3-0.5 mcg/kg/min, increase in increments of 0.5 mcg/kg/min
   • Maximum dose: 10 mcg/kg/min; duration should be as short as possible
   • Immediate onset, 1-2 minute duration
   • Caution with high intracranial pressure or azotemia
   • For infusion rates ≥4-10 mcg/kg/min or duration >30 min, thiosulfate should be coadministered to prevent cyanide toxicity 1, 3

4. Labetalol (combined alpha and beta-blocker)

   • Initial dose: 0.3-1.0 mg/kg (maximum 20 mg) slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion
   • Onset: 10-20 minutes, duration: 1-4 hours 1

Special Considerations

Acute Intracerebral Hemorrhage

• Immediate BP lowering is not recommended for patients with SBP <220 mmHg
• In patients with SBP ≥220 mmHg, careful acute BP lowering with IV therapy to <180 mmHg should be considered 1

Cautions and Contraindications

• Avoid short-acting nifedipine as it is no longer considered acceptable in the initial treatment of hypertensive emergencies due to risk of precipitous BP drops 1
• Sodium nitroprusside should be used with caution due to risk of cyanide toxicity with prolonged use 4, 5
• Hydralazine has unpredictable response and prolonged duration of action, making it less desirable for most hypertensive emergencies 1

Monitoring and Follow-up

• Continuous BP monitoring is essential during treatment
• Intra-arterial BP monitoring is recommended for sodium nitroprusside to prevent "overshoot" 1
• Monitor for signs of excessive BP reduction that may precipitate renal, cerebral, or coronary ischemia 1
• Prepare for transition to oral antihypertensive therapy once the patient is stabilized

Prognosis

The 1-year mortality rate associated with untreated hypertensive emergencies exceeds 79%, with a median survival of only 10.4 months, highlighting the critical importance of prompt and appropriate intervention 1.