What medications can be given to a patient with acute hypertension?

Management of Acute Elevated Blood Pressure

For acute hypertensive emergencies, intravenous medications including labetalol, nicardipine, clevidipine, or nitroprusside should be administered immediately with careful blood pressure monitoring, while hypertensive urgencies can be managed with oral agents such as captopril 25mg. 1, 2

Distinguishing Hypertensive Urgency vs. Emergency

First, determine if the patient has a hypertensive urgency or emergency:

• Hypertensive Emergency: BP >180/120 mmHg WITH evidence of acute end-organ damage

  • Requires immediate IV therapy and ICU admission
  • Examples: hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke, acute MI, pulmonary edema, aortic dissection, eclampsia

• Hypertensive Urgency: BP >180/120 mmHg WITHOUT evidence of acute end-organ damage

  • Can be managed with oral medications
  • Does not require immediate hospitalization

Treatment of Hypertensive Emergency

Blood Pressure Reduction Goals:

• Reduce BP by no more than 25% within the first hour
• Then to 160/100 mmHg within next 2-6 hours
• Gradually normalize over 24-48 hours 1
• For aortic dissection: reduce SBP to <120 mmHg within first hour 2

First-line IV Medications:

1. Labetalol:

   • Initial 0.3-1.0 mg/kg (maximum 20 mg) slow IV injection every 10 min
   • Or 0.4-1.0 mg/kg/h IV infusion up to 3 mg/kg/h
   • Maximum cumulative dose: 300 mg 1, 2

2. Nicardipine:

   • Initial 5 mg/h, increasing by 2.5 mg/h every 5 min
   • Maximum 15 mg/h 1, 2

3. Clevidipine:

   • Initial 1-2 mg/h, doubling every 90 seconds until BP approaches target
   • Maximum 32 mg/h; maximum duration 72 hours 1, 2

4. Sodium Nitroprusside:

   • Initial 0.3-0.5 mcg/kg/min
   • Increase in increments of 0.5 mcg/kg/min
   • Maximum 10 mcg/kg/min
   • Use for shortest duration possible due to cyanide toxicity risk 1, 2
   • Consider alternative agents when possible 3, 4

Medication Selection Based on Clinical Presentation:

Clinical Presentation	First-Line Treatment	Alternative
Most hypertensive emergencies	Labetalol	Nicardipine
Acute coronary event	Nitroglycerin	Labetalol
Acute pulmonary edema	Nitroglycerin + loop diuretic	Labetalol + loop diuretic
Aortic dissection	Esmolol + Nitroprusside	Labetalol, Nicardipine
Hypertensive encephalopathy	Labetalol	Nicardipine, Nitroprusside
Acute ischemic stroke (BP >220/120 mmHg)	Labetalol	Nicardipine
Acute hemorrhagic stroke (SBP >180 mmHg)	Labetalol	Nicardipine

Treatment of Hypertensive Urgency

Oral Medication Options:

1. Captopril:

   • Initial dose: 25 mg orally
   • Take one hour before meals
   • Can be repeated if needed 2, 5
   • For patients previously on antihypertensives, consider starting at 6.25-12.5 mg to minimize hypotension 5

2. Other options:

   • ACE inhibitors or ARBs
   • Beta-blockers (e.g., metoprolol)
   • Calcium channel blockers 2

Monitoring:

• Monitor vital signs every 30 minutes for first 2 hours
• Ensure BP stability before discharge
• Schedule follow-up within 24 hours 2

Important Cautions

1. Avoid rapid BP reduction - can cause cerebral, renal, or coronary ischemia

2. Avoid these medications for hypertensive urgencies:

   • Immediate-release nifedipine (risk of unpredictable hypotension) 3, 6
   • Hydralazine (unpredictable response) 3, 4

3. Special considerations:

   • Beta-blockers: contraindicated in reactive airway disease, heart block, bradycardia
   • ACE inhibitors: contraindicated in pregnancy and bilateral renal artery stenosis 2
   • Use beta-blockers with caution in suspected pheochromocytoma or cocaine toxicity 2

4. Untreated hypertensive emergencies have >79% one-year mortality rate 1, 2

Remember that prompt recognition and appropriate management of hypertensive emergencies can significantly reduce morbidity and mortality. The treatment approach should be tailored based on the clinical presentation and presence of end-organ damage.