From the Guidelines
The management of a hypertensive emergency involves prompt recognition, hospitalization, and intravenous antihypertensive medications to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, with the choice of medication depending on the presenting condition, as outlined in the 2019 ESC Council on Hypertension position document 1. The goal of treatment is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment, with the therapeutic goal being to reduce blood pressure to a safe level, usually <140 mmHg, in the first hour of treatment for certain conditions such as aortic dissection, severe preeclampsia or eclampsia, and pheochromocytoma with hypertensive crisis, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. Some key considerations in the management of hypertensive emergencies include:
- The type of acute organ damage is the principal determinant of the drug of choice, target blood pressure, and timeframe in which blood pressure should be lowered, as stated in the 2019 ESC Council on Hypertension position document 1.
- First-line medications include nicardipine, labetalol, or clevidipine, with sodium nitroprusside being effective but requiring careful monitoring due to cyanide toxicity risk with prolonged use, as noted in the example answer.
- The specific medication choice depends on the presenting condition, such as using labetalol or esmolol for aortic dissection, avoiding beta-blockers in acute heart failure, and preferring nicardipine for stroke, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1 and the 2019 ESC Council on Hypertension position document 1.
- Once stabilized, transition to oral medications should occur with close follow-up to adjust the long-term regimen, as recommended in the example answer. The urgency of treatment stems from the risk of progressive damage to vital organs including the brain, heart, kidneys, and eyes if hypertension remains uncontrolled, highlighting the importance of prompt and appropriate management of hypertensive emergencies, as emphasized in the 2019 ESC Council on Hypertension position document 1.
From the FDA Drug Label
For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved. For more rapid blood pressure reduction, titrate every 5 minutes.
Titration
For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved. For more rapid blood pressure reduction, titrate every 5 minutes.
The management of a hypertensive emergency with nicardipine (IV) involves:
- Initiating therapy at a rate of 5 mg/hr for a gradual reduction in blood pressure
- Increasing the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr until desired blood pressure reduction is achieved
- Titrating every 5 minutes for more rapid blood pressure reduction
- Adjusting the rate of infusion as needed to maintain desired response 2
The management of a hypertensive emergency with clevidipine (IV) involves:
- Starting at a dose of 2 mg/hour and force-titrating in 2-fold increments at 3-minute intervals for doses above 2 mg/hour
- The estimated infusion rate necessary to achieve half of the maximal effect was approximately 10 mg/hour 3
From the Research
Management of Hypertensive Emergency
The management of a hypertensive emergency involves immediate reduction in blood pressure to prevent or minimize end-organ damage. The primary goal of intervention is to safely reduce blood pressure, and this requires treatment with a titratable short-acting intravenous (IV) antihypertensive agent 4, 5.
Treatment Options
Several IV antihypertensive agents are available for the treatment of hypertensive emergencies, including:
- Clevidipine
- Labetalol
- Esmolol
- Fenoldopam
- Nicardipine
- Sodium nitroprusside (although its use is not recommended due to its toxicity) 4, 5, 6 Other agents that may be used include hydralazine, nitroglycerin, and enalaprilat, but their use may be limited by their side effects or toxicity 6, 7.
Patient Management
Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents 4, 5. The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 6. The goal is to reduce mean arterial pressure by approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours, while avoiding hypoperfusion 8.
Monitoring and Follow-up
Close monitoring of blood pressure and end-organ function is essential in the management of hypertensive emergencies. Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy, and the patient can be moved out of the ICU 8. Long-term follow-up is necessary to ensure adequate control of hypertension and prevent further target-organ damage and recurrence of another hypertensive emergency 8.