Goal Mean Arterial Pressure for Nicardipine in Elderly Patients
When initiating nicardipine in elderly patients, the target mean arterial pressure (MAP) should be maintained at 65-70 mmHg, with a systolic blood pressure target of <150 mmHg for those aged ≥80 years.
Evidence-Based Recommendations for MAP Targets
The optimal MAP target when using nicardipine in elderly patients depends on several factors, including age, comorbidities, and clinical context:
Age-Specific Targets
Patients aged 65-79 years:
- Target systolic BP: <140 mmHg (if otherwise healthy) 1
- Target MAP: 65-70 mmHg
Patients aged ≥80 years:
Clinical Context Considerations
Hypertensive Emergency Management
When using nicardipine for hypertensive emergencies in elderly patients:
- For patients without compelling conditions: reduce SBP by no more than 25% within the first hour, then to 160/100 mmHg within 2-6 hours, and cautiously to normal over 24-48 hours 2
- For compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma crisis): reduce SBP to <140 mmHg during the first hour 2
Sepsis Management
- For elderly patients with sepsis requiring nicardipine, maintain MAP at 65 mmHg 2
- Higher MAP targets (75-85 mmHg) have not shown mortality benefits but increase the risk of cardiac arrhythmias 2
Dosing and Administration Guidelines
IV Nicardipine Administration
- Initial dosing: Start at 5 mg/hr, increasing every 5 minutes by 2.5 mg/hr to maximum 15 mg/hr 2
- Elderly considerations: Use the low-end dose range and monitor closely 2, 3
- Monitoring: Continuous BP monitoring is recommended during IV administration 2
Oral Nicardipine Administration
- Initial dose: 20 mg three times daily 4
- Titration: Allow at least 3 days before increasing dose to ensure steady-state plasma concentrations 4
- Blood pressure assessment: Measure BP at trough (8 hours after dosing) and 1-2 hours after dosing during initiation 4
Precautions and Monitoring
Special Considerations for Elderly
- Orthostatic hypotension: Monitor for orthostatic changes, though studies suggest nicardipine has minimal effect on orthostatic BP in elderly 5
- Cerebral perfusion: Avoid reducing SBP below 120 mmHg in elderly as this may compromise cerebral perfusion 1
- Frailty assessment: For elderly patients with high comorbidity burden and limited life expectancy, clinical judgment and a team-based approach should guide MAP targets 2
Monitoring Parameters
- Monitor BP every 5-15 minutes during initial titration
- Once stabilized, monitor every 1-2 hours
- Assess for signs of end-organ perfusion (urine output, mental status, etc.)
- Monitor for adverse effects: headache, flushing, and phlebitis at infusion site 6
Conclusion
When initiating nicardipine in elderly patients, targeting a MAP of 65-70 mmHg balances the need for blood pressure control with maintaining adequate organ perfusion. For those ≥80 years, a higher systolic target of <150 mmHg is appropriate based on multiple guidelines. Careful titration and close monitoring are essential to minimize adverse effects while achieving therapeutic goals.