What is the management for a patient presenting with a hypertensive crisis?

Management of Hypertensive Crisis

The management of hypertensive crisis requires immediate hospitalization with continuous blood pressure monitoring and administration of intravenous antihypertensive medications for hypertensive emergencies, while hypertensive urgencies can be managed with oral antihypertensive agents. 1

Definition and Classification

• Hypertensive crisis is defined as severe blood pressure elevation (>180/120 mmHg) that requires immediate medical attention 2, 1
• Hypertensive emergencies: Severe BP elevation with evidence of new or worsening target organ damage requiring immediate BP reduction 2, 1
• Hypertensive urgencies: Severe BP elevation without progressive target organ dysfunction, often in non-compliant or inadequately treated hypertensive patients 2, 1

Initial Assessment and Triage

• Rapidly determine if target organ damage is present to differentiate between emergency and urgency 1
• Common presentations of target organ damage include:
  • Heart: acute pulmonary edema, coronary ischemia/acute MI, heart failure 1
  • Brain: hypertensive encephalopathy, acute stroke (ischemic or hemorrhagic) 1
  • Kidneys: acute kidney failure, thrombotic microangiopathy 1
  • Retina: advanced hypertensive retinopathy (grade III-IV) 1
  • Large arteries: acute aortic disease (aneurysm or dissection) 1

Management of Hypertensive Emergencies

• Admit to intensive care unit for continuous BP monitoring and parenteral administration of appropriate agents 2
• The goal is to reduce BP safely, not necessarily to normal levels immediately 2, 1
• BP reduction targets:
  • Reduce SBP by no more than 25% within the first hour 2, 1
  • If stable, reduce to 160/100 mmHg within the next 2-6 hours 2, 1
  • Then cautiously reduce to normal during the following 24-48 hours 2, 1

First-Line Intravenous Medications

• Nicardipine: Start with 5 mg/h, increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h 2, 3

  • Advantages: No dose adjustment needed for elderly, effective for most hypertensive emergencies 2
  • Contraindicated in advanced aortic stenosis 2

• Labetalol: Initial 20 mg IV over 2 minutes, then 20-80 mg every 10 minutes up to a total dose of 300 mg 2, 1

  • Particularly useful for most hypertensive emergencies except acute heart failure 2, 1
  • Contraindicated in patients with asthma, heart block, or acute heart failure 1

• Sodium nitroprusside: Initial 0.3-0.5 μg/kg/min, increase in increments of 0.5 μg/kg/min to maximum 10 μg/kg/min 2, 4

  • Indicated for immediate BP reduction in hypertensive crises 4
  • Treatment duration should be as short as possible due to risk of cyanide toxicity 2, 1
  • Intra-arterial BP monitoring recommended to prevent "overshoot" 2

Medication Selection Based on Specific Conditions

• Acute coronary syndrome: Nitroglycerin (initial 5 μg/min, increase by 5 μg/min every 3-5 min to maximum 20 μg/min) 2, 1
• Acute pulmonary edema: Nitroglycerin or Nitroprusside 2, 1
• Acute aortic dissection: Esmolol and Nitroprusside or Nitroglycerin; target SBP <120 mmHg within 20 minutes 1, 5
• Hypertensive encephalopathy: Labetalol 1
• Acute stroke: Management depends on type and timing; generally, Labetalol is preferred 1

Management of Hypertensive Urgencies

• Do not require immediate BP reduction or hospitalization 2, 6
• Treat with oral antihypertensive medications 2, 1
• Gradual BP reduction over 24-48 hours 2, 7
• Often managed by reinstitution or intensification of previous antihypertensive therapy 2

Important Precautions

• Avoid precipitous BP reduction that can lead to renal, cerebral, or coronary ischemia 2, 1
• Short-acting nifedipine is no longer considered acceptable for initial treatment of hypertensive emergencies or urgencies 2, 1, 8
• Sodium nitroprusside should be used with caution due to risk of cyanide toxicity, especially with prolonged use 1, 8
• Large BP reductions (>50% decrease in mean arterial pressure) have been associated with ischemic stroke and death 1
• Change infusion site every 12 hours if administered via peripheral vein 3

Transition to Oral Therapy

• Oral antihypertensive therapy can usually be instituted after 6-12 hours of parenteral therapy 5
• When switching to oral nicardipine, administer the first dose 1 hour prior to discontinuation of the infusion 3
• Concomitant longer-acting antihypertensive medication should be administered to minimize the duration of treatment with sodium nitroprusside 4