What medications can be used to treat acute hypertension in a hospital setting without decreasing heart rate?

Medications for Acute Hypertension Without Decreasing Heart Rate

For acute hypertension in hospitalized patients requiring blood pressure control without decreasing heart rate, nicardipine and hydralazine are the preferred agents as they effectively lower blood pressure without significant bradycardic effects. 1, 2

First-Line Options

• Nicardipine (IV): A dihydropyridine calcium channel blocker that provides dose-dependent decreases in blood pressure without significant negative chronotropic effects 2

  • Dosing: 5-15 mg/h as continuous IV infusion, starting at 5 mg/h, increasing every 15-30 min by 2.5 mg until target BP is reached 1
  • Onset: 5-15 minutes; Duration: 30-40 minutes 1
  • Particularly effective for severe or postoperative hypertension with average maintenance dose of 8.0 mg/h for severe hypertension and 3 mg/h for postoperative hypertension 2

• Clevidipine: An ultra-short acting calcium channel blocker for intravenous use 1

  • Onset: 2-3 minutes; Duration: 5-15 minutes 1
  • Dosing: 2 mg/h IV infusion, increase every 2 min with 2 mg/h until goal BP is reached 1
  • Advantage: Rapid onset and offset of action allows for precise titration 3

Alternative Options

• Fenoldopam: A selective dopamine-1 receptor agonist 1

  • Onset: 5-15 minutes; Duration: 30-60 minutes 1
  • Dosing: 0.1 mg/kg/min IV infusion, increase every 15 min with 0.05 to 0.1 mg/kg/min increments until goal BP is reached 1
  • Advantage: May improve renal blood flow while lowering blood pressure 3

• Hydralazine: A direct arterial vasodilator 1

  • Particularly useful in pregnancy-related hypertensive emergencies 4
  • May cause reflex tachycardia, which can be beneficial when heart rate preservation is desired 5

• Nitroglycerine: Primarily for hypertension with concurrent coronary ischemia 1

  • Onset: 1-5 minutes; Duration: 3-5 minutes 1
  • Dosing: 5-200 μg/min, 5 μg/min increase every 5 min 1
  • Note: May cause reflex tachycardia, making it suitable when heart rate preservation is desired 1

Situation-Specific Recommendations

For Acute Coronary Events with Hypertension:

• Nitroglycerine is first-line treatment (reduces afterload without decreasing heart rate) 1
• Urapidil or Nicardipine as alternatives 1

For Acute Cardiogenic Pulmonary Edema:

• Nitroprusside or Nitroglycerine (with loop diuretic) 1
• Urapidil (with loop diuretic) as alternative 1

For Hypertensive Encephalopathy:

• Nicardipine is a good alternative to labetalol when heart rate preservation is needed 1

Medications to Avoid

• Beta-blockers (labetalol, esmolol, metoprolol): These will decrease heart rate and should be avoided when heart rate preservation is desired 1
• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem): These have significant negative chronotropic effects 1
• Immediate-release nifedipine: Associated with unpredictable blood pressure reduction and reflex tachycardia 1, 3

Clinical Pearls

• Always monitor patients closely during acute blood pressure management, particularly for signs of end-organ hypoperfusion 1
• The magnitude and rate of blood pressure reduction should be tailored to the specific clinical scenario - generally aim for a 10-15% reduction in mean arterial pressure in the first hour 6
• For most hypertensive emergencies without specific target organ involvement, reducing mean arterial pressure by 20-25% over several hours is appropriate 1
• Sodium nitroprusside should be used with caution due to risk of cyanide toxicity with prolonged use 1, 7
• After initial IV therapy, transition to oral antihypertensives should be considered within 6-12 hours when the patient is stable 6

Remember that the choice of antihypertensive agent should consider the specific clinical scenario, comorbidities, and the need to preserve heart rate in your patient.