What is the management of hypertensive emergency (severe uncontrolled hypertension)?

From the Guidelines

Hypertensive emergency requires immediate blood pressure reduction to prevent end-organ damage, and the most recent guidelines recommend starting with IV antihypertensive medications in a monitored setting, aiming for a controlled reduction in blood pressure. The management of hypertensive emergency is primarily driven by the type of acute organ damage, which determines the choice of antihypertensive agent, target blood pressure, and timeframe for blood pressure reduction 1. According to the 2020 International Society of Hypertension global hypertension practice guidelines, a hypertensive emergency is defined as substantially elevated blood pressure associated with acute organ damage, and requires rapid diagnostic workup and immediate blood pressure reduction to avoid progressive organ failure 1.

Key Considerations

• The type of acute organ damage is the principal determinant of the management strategy, including the choice of antihypertensive agent, target blood pressure, and timeframe for blood pressure reduction 1.
• Patients with acute hypertension-mediated organ damage, such as stroke, acute hypertensive microangiopathy, and encephalopathy, cardiogenic pulmonary edema, coronary ischemia, and acute aortic disease, require immediate blood pressure reduction to prevent further organ damage 1.
• The swiftness and magnitude of blood pressure reduction, as well as the type of blood pressure-lowering medication, is strongly dependent on the clinical context, with rapid blood pressure lowering required in patients with pulmonary edema and acute aortic dissection 1.

Recommended Treatment

• First-line agents for hypertensive emergency include labetalol, nicardipine, or clevidipine, which can be administered intravenously in a monitored setting 1.
• For patients with aortic dissection, esmolol plus vasodilator therapy is recommended, while for eclampsia/preeclampsia, IV labetalol, IV hydralazine, or oral nifedipine can be used 1.
• Nitroprusside should be reserved for resistant cases due to the risk of cyanide toxicity with prolonged use 1.
• Concurrent management includes airway protection, neurological monitoring, ECG monitoring, establishing IV access, and addressing the underlying cause, with the goal of preventing further organ damage while avoiding cerebral, coronary, or renal hypoperfusion that could result from excessive blood pressure lowering 1.

From the FDA Drug Label

The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. With constant infusion, blood pressure begins to fall within minutes. It reaches about 50% of its ultimate decrease in about 45 minutes 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. In patients with severe or postoperative hypertension), nicardipine hydrochloride injection (5 to 15 mg/hr) produced dose-dependent decreases in blood pressure.

The management of hypertensive emergency (severe uncontrolled hypertension) with nicardipine hydrochloride injection 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
• Titration can be done every 5 minutes for more rapid blood pressure reduction
• The average maintenance dose for severe hypertension is 8.0 mg/hr 2 2

From the Research

Management of Hypertensive Emergency

The management of hypertensive emergency, which is characterized by severe uncontrolled hypertension with acute end-organ damage, requires immediate reduction in blood pressure to prevent further damage.

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 3, 4, 5.
• Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable intravenous (IV) hypotensive agents 3, 4, 5.
• Rapid-acting IV antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 3, 4, 5, 6.

Treatment Options

The choice of treatment depends on the clinical presentation of the patient and the presence of end-organ damage.

• Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 3, 4, 5.
• Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to significant toxicities and/or side effects 3, 4, 5.
• Newer agents such as clevidipine may have considerable advantages compared to other available agents in the management of hypertensive crises 3, 4.

Patient Care

Patients with hypertensive emergencies require close monitoring and individualized care.

• 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.