What is the treatment for hypertensive emergency?

From the Guidelines

The treatment for hypertensive emergency is intravenous antihypertensive therapy with the goal of rapidly lowering blood pressure to prevent or limit further organ damage.

Preferred Drugs

• The choice of antihypertensive treatment is determined by the type of organ damage, with labetalol and nicardipine being commonly used options 1.
• Other preferred drugs for specific comorbidities include:
  • Esmolol and labetalol for acute aortic dissection 1
  • Clevidipine, nitroglycerin, and nitroprusside for acute pulmonary edema 1
  • Esmolol, labetalol, nicardipine, and nitroglycerin for acute coronary syndromes 1

Dosage and Administration

• The dosage and administration of these drugs vary, with examples including:
  • Nicardipine: initial dose of 5 mg/h, increasing every 5 min by 2.5 mg/h to a maximum of 15 mg/h 1
  • Clevidipine: initial dose of 1-2 mg/h, doubling every 90 s until blood pressure approaches target 1
  • Labetalol: initial dose of 0.3-1.0 mg/kg, slow IV injection every 10 min or 0.4-1.0 mg/kg/h IV infusion up to 3 mg/kg/h 1

Clinical Context

• The swiftness and magnitude of blood pressure reduction, as well as the type of antihypertensive medication, depends on the clinical context 1.
• Rapid blood pressure lowering is required in patients with pulmonary edema and acute aortic dissection, while blood pressure-lowering medication is generally withheld in patients with ischemic stroke 1.
• The treatment goal is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment 1.

From the Research

Treatment of Hypertensive Emergency

The treatment of hypertensive emergency involves immediate reduction in blood pressure using titratable short-acting intravenous (IV) antihypertensive agents 2, 3, 4. The primary goal of intervention is to safely reduce blood pressure and prevent further end-organ damage.

Intravenous Antihypertensive Agents

Several IV antihypertensive agents are available, including:

• Clevidipine: a newer agent with considerable advantages compared to other available agents 2
• Labetalol: produces a prompt, controlled reduction in blood pressure 3
• Esmolol: effective in controlling both supraventricular tachyarrhythmias and severe hypertension 5
• Fenoldopam: a selective post-synaptic dopaminergic receptor (DA1) with a lower incidence of side effects than sodium nitroprusside 5
• Nicardipine: a potent arteriolar vasodilator without a significant direct depressant effect on myocardium 5
• Sodium nitroprusside: although effective, its use should be avoided due to its toxicity 2, 3

Management Strategies

Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents 2, 4. The management of hypertensive emergencies should be influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities 6. Frequent nursing intervention and close monitoring are crucial to recuperation 6.

Key Considerations

• An appreciation of cerebral autoregulation is key and should underpin treatment decisions 4
• Hypertensive emergencies require intravenous antihypertensive medication, which is most safely given in high dependency or intensive care settings 4
• Patients with hypertensive urgency are often treated with medications that lower their blood pressure acutely, although there is no evidence to support this practice 4