What is the management of accelerated hypertension?

Management of Accelerated Hypertension

In accelerated hypertension, immediate treatment with intravenous antihypertensive agents is recommended, with labetalol as first-line therapy for most presentations, aiming for a controlled blood pressure reduction of 20-25% in the first few hours. 1

Definition and Classification

• Accelerated hypertension (also called malignant hypertension) is characterized by severely elevated blood pressure with acute hypertension-mediated organ damage, typically manifesting as retinopathy, acute renal failure, and/or thrombotic microangiopathy 1
• Hypertensive emergencies require immediate blood pressure reduction to limit extension or promote regression of acute organ damage 1
• Patients without acute end-organ damage have hypertensive urgency, not emergency, and can usually be treated with oral agents 1

Initial Assessment and Management

• The type of target organ damage determines the choice of treatment, target BP, and timeframe for BP reduction 1
• For malignant hypertension with or without thrombotic microangiopathy or acute renal failure, aim to reduce mean arterial pressure by 20-25% over several hours 1
• Patients with hypertensive emergencies should be admitted for close monitoring and, in most cases, treated with intravenous BP-lowering agents 1

Pharmacological Management

First-line Treatments

• Intravenous labetalol is recommended as first-line treatment for most hypertensive emergencies, including malignant hypertension and hypertensive encephalopathy 1
• For severe hypertension, drug treatment with IV labetalol, oral methyldopa, or nifedipine is recommended 1
• Nicardipine (calcium channel blocker) is an effective alternative that produces dose-dependent decreases in blood pressure 2

Alternative Agents

• Sodium nitroprusside, nicardipine, and urapidil are effective alternatives for malignant hypertension 1
• For patients with acute coronary events, nitroglycerin is the first-line agent 1
• For acute cardiogenic pulmonary edema, nitroprusside or nitroglycerin (with loop diuretic) is recommended 1
• Intravenous hydralazine is considered a second-line option 1

Dosing and Administration

• For nicardipine: initiate therapy at 5 mg/hr, increase by 2.5 mg/hr every 15 minutes up to 15 mg/hr until desired blood pressure reduction is achieved 2
• For more rapid blood pressure reduction, titration can be done every 5 minutes 2
• Avoid excessive or rapid reductions in blood pressure as they may cause complications such as cerebral infarction or damage to myocardium and kidneys 1

Special Considerations

Stroke Management

• In acute ischemic stroke with BP >220/120 mmHg, careful BP lowering with IV therapy to reduce mean arterial pressure by 15% is recommended 1
• For acute hemorrhagic stroke with systolic BP >180 mmHg, immediate BP reduction to 130-180 mmHg is recommended 1
• In patients with acute intracerebral hemorrhage, immediate BP lowering is not recommended for systolic BP <220 mmHg 1

Other Specific Situations

• For autonomic hyperreactivity due to stimulant intoxication, benzodiazepines should be initiated first, followed by phentolamine, nicardipine, or nitroprusside if needed 1
• In pheochromocytoma, phentolamine, nitroprusside, urapidil, or nicardipine are recommended 1

Follow-up and Long-term Management

• Frequent monitoring (at least monthly visits) in a specialized setting is recommended until target BP is reached 1
• Extended follow-up is necessary until hypertension-mediated organ damage (renal function, proteinuria, left ventricular mass) has regressed 1
• Patients who have experienced a hypertensive emergency remain at increased risk of cardiovascular and renal disease compared to hypertensive patients without a history of emergency 1

Common Pitfalls to Avoid

• Avoid excessive or rapid blood pressure reduction, which can lead to organ hypoperfusion 1
• Sodium nitroprusside should be used with caution due to its toxicity profile 3, 4
• Avoid immediate-release nifedipine, nitroglycerin (except in specific indications), and hydralazine as first-line agents due to unpredictable responses 4
• Do not attempt to normalize blood pressure during the initial emergency department visit 1