What is the management of a hypertensive emergency?

From the Guidelines

Hypertensive emergency should be managed with immediate intravenous antihypertensive therapy, with first-line medications including labetalol, nicardipine, or clevidipine, and a goal to reduce mean arterial pressure by no more than 25% within the first hour. The management of hypertensive emergency requires a comprehensive approach, including admission to an intensive care unit for continuous blood pressure monitoring and intravenous antihypertensive therapy.

• The choice of antihypertensive medication depends on the type of organ damage and the clinical presentation, with labetalol, nicardipine, and clevidipine being commonly used options 1.
• The goal of treatment is to reduce mean arterial pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and then to normal over the next 24-48 hours 1.
• Exceptions to this approach include aortic dissection, where immediate reduction to <120 mmHg systolic is recommended, and ischemic stroke, where aggressive BP lowering may be harmful 1.
• Concurrent management of complications is essential, including anticonvulsants for hypertensive encephalopathy, diuretics for pulmonary edema, or specific interventions for myocardial infarction 1.
• The underlying cause of hypertensive emergency should be identified and addressed, as conditions like pheochromocytoma, preeclampsia, or medication non-compliance require specific treatments 1.
• Hypertensive emergencies are life-threatening because severely elevated blood pressure can cause rapid damage to the brain, heart, kidneys, and other vital organs through mechanisms including endothelial injury, fibrinoid necrosis of arterioles, and tissue ischemia 1. According to the most recent guidelines, the management of hypertensive emergency should be based on the clinical presentation and the type of organ damage, with a focus on reducing blood pressure in a controlled and safe manner 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 the prompt recognition of the condition and the appropriate diagnostic tests and triage to lead to the adequate reduction of blood pressure, ameliorating the incidence of fatal outcomes 4, 5.

• Severely hypertensive patients with acute end-organ damage (hypertensive emergencies) warrant admission to an intensive care unit for immediate reduction of blood pressure with a short-acting titratable intravenous antihypertensive medication 4, 5, 6, 7.
• Rapid and short-lived intravenous medications commonly used are:
  • Labetalol
  • Esmolol
  • Fenoldopam
  • Nicardipine
  • Sodium nitroprusside
  • Clevidipine 4, 5, 6, 7
• Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided 4, 5.
• Sodium nitroprusside should be used with caution because of its toxicity 4, 5, 7.

Treatment Approach

The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 5.

• The appropriate therapeutic approach of each patient will depend on their clinical presentation 5.
• Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents 5, 6, 7, 8.
• 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.
• Tailoring drug selection according to individual patient characteristics can optimize the management and potential outcomes of patients with hypertensive emergency 6.

Blood Pressure Reduction

• For aortic dissection, the systolic BP target is lower than 120 mm Hg, to be achieved during the first 20 minutes using a beta-blocker (typically esmolol) and a vasodilator to reduce both shear stress on the aortic tear and the BP, respectively 7.
• Most authors suggest a reduction in mean arterial pressure of approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours 7.
• Hypoperfusion can result if the BP is lowered too suddenly or too far (eg, into the range of <140/90 mm Hg) 7.