What medications are used to treat hypertensive (high blood pressure) urgency and emergency?

Management of Hypertensive Urgency and Emergency

For hypertensive emergencies (BP >180/120 mmHg with acute target organ damage), immediate IV therapy with nicardipine, clevidipine, or labetalol is recommended as first-line treatment, while hypertensive urgencies (BP >180/120 mmHg without target organ damage) should be managed with oral medications like captopril, labetalol, amlodipine, or clonidine. 1

Differentiating Hypertensive Urgency vs. Emergency

Hypertensive Emergency

• Definition: BP >180/120 mmHg WITH evidence of acute target organ damage
• Requires: Immediate BP reduction (within minutes to hours)
• Setting: Intensive care unit with IV medications
• Target organ damage includes:
  • Hypertensive encephalopathy
  • Intracranial hemorrhage
  • Acute ischemic stroke
  • Acute myocardial infarction
  • Left ventricular failure with pulmonary edema
  • Unstable angina
  • Aortic dissection
  • Acute renal failure
  • Eclampsia

Hypertensive Urgency

• Definition: BP >180/120 mmHg WITHOUT evidence of acute target organ damage
• Requires: BP reduction within 24 hours
• Setting: Can often be managed outpatient with oral medications
• Goal: Reduce BP by approximately 15% within the first 24 hours

Management of Hypertensive Emergency

First-Line IV Medications 1

1. Nicardipine

   • Initial: 5 mg/h IV
   • Titration: Increase by 2.5 mg/h every 5 minutes
   • Maximum: 15 mg/h

2. Clevidipine

   • Initial: 1-2 mg/h IV
   • Titration: Double dose every 90 seconds initially, then adjust more gradually

3. Labetalol

   • Initial: 0.3-1.0 mg/kg IV (maximum 20 mg)
   • Titration: Slow injection every 10 minutes or 0.4-1.0 mg/kg/h IV infusion

4. Esmolol

   • Initial: 0.5-1 mg/kg IV bolus
   • Titration: 50-300 μg/kg/min continuous infusion

5. Sodium Nitroprusside (use with caution)

   • Initial: 0.3-0.5 mcg/kg/min IV
   • Titration: Increase in increments of 0.5 mcg/kg/min
   • Caution: Risk of cyanide toxicity
   • FDA approved for immediate reduction of blood pressure in hypertensive crises 2

Condition-Specific BP Targets 1

• Aortic dissection: <120 mmHg systolic within the first hour
• Severe preeclampsia/eclampsia: <140 mmHg systolic within the first hour
• Pheochromocytoma: <140 mmHg systolic within the first hour
• Hypertensive encephalopathy: Reduce mean arterial pressure by 20-25% immediately
• Acute ischemic stroke with BP >220/120 mmHg: Reduce mean arterial pressure by 15% within the first hour
• Acute hemorrhagic stroke with BP >180 mmHg: 130-180 mmHg systolic immediately
• Acute coronary event: <140 mmHg systolic immediately
• Cardiogenic pulmonary edema: <140 mmHg systolic immediately

Management of Hypertensive Urgency

First-Line Oral Medications 1

1. Captopril (ACE inhibitor)
2. Labetalol (combined alpha and beta-blocker)
3. Amlodipine (calcium channel blocker)
4. Clonidine (central alpha-2 agonist)

Monitoring Protocol 1

• BP checks every 30 minutes for the first 2 hours
• Every hour for the next 4 hours
• Every 2-4 hours for the next 18 hours
• Monitor for symptoms: dizziness, altered mental status, chest pain, shortness of breath

Important Considerations and Pitfalls

Critical Pitfalls to Avoid

1. Excessive BP lowering - Aim for 10-15% reduction over 24 hours, not normalization 1
2. Failure to distinguish urgency from emergency - Careful assessment for target organ damage is essential 1
3. Using sodium nitroprusside as first-line - Despite its FDA approval, newer research indicates it should be used with caution due to toxicity concerns 3, 4
4. Using immediate-release nifedipine, nitroglycerin, or hydralazine as first-line - These agents are associated with significant toxicities and adverse effects 3

Medication Considerations

• Elderly patients: Start with lower doses, monitor for orthostatic hypotension, avoid rapid BP lowering 1
• Medication reconciliation: Identify if missed doses or medication interactions are contributing factors 1
• Transition to oral therapy: Can be initiated once BP is stabilized, typically after 6-12 hours of parenteral therapy 1

Prognosis

• Untreated hypertensive emergencies have a one-year mortality rate of >79% and a median survival of only 10.4 months 1
• Prompt recognition and appropriate treatment significantly improve outcomes

Monitoring and Follow-up

• Cardiac monitoring during acute management
• Frequent BP checks as outlined above
• Transition to maintenance therapy once stabilized
• Implement lifestyle modifications (weight management, physical activity, smoking cessation, moderate alcohol consumption)