What is the management of a hypertensive emergency?

From the Guidelines

The management of a hypertensive emergency involves immediate treatment with intravenous antihypertensive medications to lower blood pressure by no more than 25% within the first hour, then gradually to 160/100-110 mmHg over the next 2-6 hours, with first-line medications including labetalol, nicardipine, or clevidipine, as recommended by the most recent guidelines 1, 2. The goal of treatment is to prevent or limit further hypertensive damage by a controlled blood pressure reduction, with the swiftness and magnitude of the blood pressure reduction, as well as the type of blood pressure-lowering medication, strongly dependent on the clinical context. Some key points to consider in the management of hypertensive emergencies include:

• The type of hypertensive organ damage, such as stroke, acute hypertensive microangiopathy, and encephalopathy, cardiogenic pulmonary edema, coronary ischemia, and acute aortic disease, which guides the treatment approach 1, 2.
• The need for rapid blood pressure lowering in certain situations, such as pulmonary edema and acute aortic dissection, while blood pressure-lowering medication is generally withheld in patients with ischemic stroke 2, 3.
• The importance of close hemodynamic monitoring in a clinical area with facilities for intensive care, and the use of intravenous medication to achieve controlled blood pressure reduction 1, 3.
• The recommendation to use labetalol or nicardipine as first-line medications, as they are widely available and effective in treating most hypertensive emergencies 1, 3. It is also important to note that the treatment of hypertensive emergencies should be individualized based on the patient's specific clinical context, and that the goal of treatment is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment 4, 2.

From the FDA Drug Label

Titration For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2. 5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved. For more rapid blood pressure reduction, titrate every 5 minutes.

Maintenance Adjust the rate of infusion as needed to maintain desired response.

2. 5 Conditions Requiring Infusion Adjustment Hypotension or Tachycardia: In case of hypotension or tachycardia, discontinue infusion. When blood pressure and heart rate stabilize, restart infusion at low doses such as 30 mL/hr to 50 mL/hr (3 mg/hr to 5 mg/hr) and titrate to maintain desired blood pressure.

The management of a hypertensive emergency involves the administration of nicardipine hydrochloride injection by slow continuous infusion.

• Initiation of therapy: Start with a rate of 5 mg/hr for a gradual reduction in blood pressure.
• Titration: Increase the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr until the desired blood pressure reduction is achieved.
• Rapid blood pressure reduction: Titrate every 5 minutes.
• Maintenance: Adjust the rate of infusion as needed to maintain the desired response.
• Infusion adjustment: Discontinue infusion in case of hypotension or tachycardia, and restart at a low dose when blood pressure and heart rate stabilize 5.

From the Research

Management of Hypertensive Emergency

The management of a hypertensive emergency involves the rapid controlled reduction of blood pressure to prevent or minimize end-organ damage. Key aspects of management include:

• Rapid recognition and initiation of therapy to minimize end-organ damage 6, 7, 8
• Selection of a specific intravenous antihypertensive agent based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 6, 7, 9
• Use of titratable, short-acting, intravenous antihypertensive agents, such as labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside 6, 7, 9, 8

Treatment Approach

The treatment approach for hypertensive emergencies involves:

• Reducing blood pressure by 10-20% within the first hour, and then gradually over the next 2-6 hours 8, 10
• Using oral antihypertensive therapy after 6-12 hours of parenteral therapy 8
• Considering secondary causes of hypertension after transfer from the intensive care unit 8
• Avoiding aggressive blood pressure lowering in hypertensive urgencies, instead using a gradual lowering of blood pressure over 24-48 hours with an oral medication 10

Choice of Antihypertensive Agents

The choice of antihypertensive agent depends on:

• The underlying cause of the crisis 10
• Patient demographics 10
• Cardiovascular risk and comorbidities 10
• The presence of end-organ damage 6, 7, 9
• The need for a titratable, short-acting agent 6, 7, 9, 8