What is the immediate treatment for a hypertensive crisis?

Immediate Treatment for Hypertensive Crisis

For hypertensive emergencies (BP >180/120 mmHg with evidence of end-organ damage), immediate admission to an intensive care unit is recommended for continuous monitoring and parenteral administration of appropriate antihypertensive agents. 1, 2

Classification of Hypertensive Crisis

• Hypertensive Emergency: Severe BP elevation (>180/120 mmHg) with evidence of new or worsening target organ damage requiring immediate BP reduction 1, 2
• Hypertensive Urgency: Severe BP elevation without progressive target organ damage; can usually be treated with oral BP-lowering agents 1, 2

Initial Management of Hypertensive Emergency

Blood Pressure Reduction Goals

• Reduce mean arterial BP by no more than 25% within the first hour 1, 2
• Then reduce to 160/100 mmHg within the next 2-6 hours if stable 1
• Further gradual reduction toward normal BP over the following 24-48 hours 1

Special Situations with Different BP Targets

• Aortic Dissection: Reduce SBP to <120 mmHg 1, 2
• Severe Preeclampsia/Eclampsia: Reduce SBP to <140 mmHg during the first hour 1
• Without Compelling Condition: SBP should be reduced by no more than 25% within the first hour 1

First-Line Intravenous Medications

Recommended IV Agents

• Nicardipine: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h 1, 3
• Labetalol: Initial 0.3-1.0 mg/kg dose (maximum 20 mg) slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion 1, 2
• Clevidipine: Initial 1-2 mg/h, doubling every 90 seconds until BP approaches target 1
• Sodium nitroprusside: Initial 0.3-0.5 mcg/kg/min; increase in increments of 0.5 mcg/kg/min to achieve BP target 1, 4
• Esmolol: Loading dose 500-1000 mcg/kg/min over 1 min followed by 50 mcg/kg/min infusion 1

Medication Selection Based on Specific Conditions

• Acute pulmonary edema: Nicardipine, nitroglycerin, or sodium nitroprusside 1, 2
• Aortic dissection: Labetalol or esmolol (beta-blockers) combined with vasodilator 1, 2
• Preeclampsia/eclampsia: Labetalol or nicardipine (avoid sodium nitroprusside) 1, 2
• Acute renal failure: Fenoldopam or nicardipine 5, 6

Common Pitfalls to Avoid

• Excessive rapid BP reduction: Can lead to cerebral, renal, or coronary ischemia 1, 2
• Short-acting nifedipine: No longer considered acceptable in the initial treatment of hypertensive emergencies 1, 7
• Sodium nitroprusside: Use with caution due to risk of cyanide toxicity, especially with prolonged use or renal impairment 7, 5
• Hydralazine: Can cause unpredictable and prolonged hypotension; not recommended as first-line 7, 8

Monitoring During Treatment

• Continuous BP monitoring preferably via arterial line 1
• Frequent assessment of neurological status, cardiac function, and urine output 1, 9
• Monitor for signs of end-organ damage improvement or deterioration 1, 9
• Laboratory monitoring including renal function, electrolytes, and cardiac markers 1, 9

Transition to Oral Therapy

• Begin oral antihypertensive therapy once BP is stable 1
• Gradually taper IV medications as oral agents take effect 3
• Select oral agents based on patient's comorbidities and prior medication history 1, 2