What are the prescription templates for managing hypertensive emergencies and urgencies, including various case scenarios and treatment options?

Prescription Templates for Hypertensive Emergencies and Urgencies

Distinguishing Emergency from Urgency

The critical distinction is target organ damage, not the absolute blood pressure number—hypertensive emergency requires immediate IV therapy in an ICU, while hypertensive urgency can be managed with oral agents and outpatient follow-up. 1

• Hypertensive Emergency: BP >180/120 mmHg WITH acute/progressive target organ damage (encephalopathy, stroke, acute MI, pulmonary edema, aortic dissection, acute renal failure, eclampsia) 1
• Hypertensive Urgency: BP >180/120 mmHg WITHOUT acute target organ damage 2

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HYPERTENSIVE EMERGENCIES: IV Prescription Templates

General Principles for ALL Emergencies

Admit to ICU for continuous arterial BP monitoring and parenteral therapy. 1

Blood Pressure Reduction Targets:

• WITHOUT compelling condition: Reduce SBP by maximum 25% within first hour → then to 160/100 mmHg over next 2-6 hours → then cautiously to normal over 24-48 hours 1
• WITH compelling condition (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma): Reduce SBP to <140 mmHg within first hour; <120 mmHg for aortic dissection 1

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Template 1: Malignant Hypertension / Hypertensive Encephalopathy

Rx: Labetalol IV (First-Line)

• Loading: 0.3-1.0 mg/kg (maximum 20 mg) slow IV push over 2 minutes, repeat every 10 minutes as needed 1
• OR continuous infusion: 0.4-1.0 mg/kg/hour, titrate up to 3 mg/kg/hour (maximum cumulative 300 mg) 1
• Target: Reduce MAP by 20-25% over several hours 1

Alternative Rx: Nicardipine IV

• Initial: 5 mg/hour IV infusion 1
• Titrate: Increase by 2.5 mg/hour every 5 minutes to maximum 15 mg/hour 1

Alternative Rx: Sodium Nitroprusside IV (use with caution)

• Initial: 0.3-0.5 mcg/kg/min 1
• Titrate: Increase by 0.5 mcg/kg/min increments to maximum 10 mcg/kg/min 1
• CRITICAL: For rates ≥4-10 mcg/kg/min or duration >30 minutes, coadminister thiosulfate to prevent cyanide toxicity 1
• Avoid in encephalopathy: Nitroprusside increases intracranial pressure; labetalol preferred as it preserves cerebral blood flow 1

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Template 2: Acute Ischemic Stroke

Only treat if BP >220/120 mmHg OR if candidate for thrombolysis with BP >185/110 mmHg 1

Rx: Labetalol IV (First-Line)

• 0.3-1.0 mg/kg (maximum 20 mg) slow IV push every 10 minutes 1
• Target: Reduce MAP by 15% over 1 hour 1

Alternative Rx: Nicardipine IV

• Initial: 5 mg/hour, titrate by 2.5 mg/hour every 5 minutes to maximum 15 mg/hour 1

CRITICAL CAVEAT: Generally withhold BP-lowering in acute ischemic stroke unless extreme elevation or thrombolysis planned 1

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Template 3: Acute Hemorrhagic Stroke (Intracerebral Hemorrhage)

Rx: Labetalol IV (First-Line)

• 0.3-1.0 mg/kg slow IV push every 10 minutes 1
• Target: SBP 130-180 mmHg immediately 1

Alternative Rx: Nicardipine IV

• Initial: 5 mg/hour, titrate by 2.5 mg/hour every 5 minutes 1

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Template 4: Acute Coronary Syndrome (MI/Unstable Angina)

Rx: Nitroglycerin IV (First-Line)

• Initial: 5 mcg/min 1
• Titrate: Increase by 5 mcg/min every 3-5 minutes to maximum 20 mcg/min 1
• Target: SBP <140 mmHg immediately 1

Alternative Rx: Labetalol IV

• 0.3-1.0 mg/kg slow IV push every 10 minutes 1

CRITICAL: Avoid nitroprusside in acute coronary syndromes due to coronary steal phenomenon 1

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Template 5: Acute Cardiogenic Pulmonary Edema

Rx: Nitroglycerin IV PLUS Loop Diuretic (First-Line)

• Nitroglycerin: Initial 5 mcg/min, titrate by 5 mcg/min every 3-5 minutes 1
• PLUS Furosemide: 40-80 mg IV push 1
• Target: SBP <140 mmHg immediately 1

Alternative Rx: Sodium Nitroprusside IV PLUS Loop Diuretic

• Nitroprusside: Initial 0.3-0.5 mcg/kg/min, titrate by 0.5 mcg/kg/min 1
• PLUS Furosemide: 40-80 mg IV push 1

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Template 6: Acute Aortic Dissection

Rx: Esmolol IV PLUS Nitroprusside or Nitroglycerin (First-Line)

• Esmolol: Loading 500-1000 mcg/kg over 1 minute, then 50 mcg/kg/min infusion; titrate by 50 mcg/kg/min increments to maximum 200 mcg/kg/min 1
• PLUS Nitroprusside: 0.3-0.5 mcg/kg/min, titrate to effect 1
• Target: SBP <120 mmHg AND heart rate <60 bpm within first hour 1

Alternative Rx: Labetalol IV (monotherapy)

• 0.3-1.0 mg/kg slow IV push every 10 minutes 1

CRITICAL: Beta-blockade MUST precede vasodilation to prevent reflex tachycardia and increased aortic shear stress 1

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Template 7: Eclampsia / Severe Preeclampsia

Rx: Labetalol IV PLUS Magnesium Sulfate (First-Line)

• Labetalol: 0.3-1.0 mg/kg slow IV push every 10 minutes 1
• PLUS Magnesium Sulfate: 4-6 g IV loading dose over 20 minutes, then 1-2 g/hour maintenance 1
• Target: SBP <160 mmHg AND DBP <105 mmHg immediately 1

Alternative Rx: Nicardipine IV PLUS Magnesium Sulfate

• Nicardipine: Initial 5 mg/hour, titrate by 2.5 mg/hour every 5 minutes 1
• PLUS Magnesium Sulfate as above 1

Alternative Rx: Hydralazine IV PLUS Magnesium Sulfate

• Hydralazine: 10 mg slow IV push (maximum initial 20 mg), repeat every 4-6 hours 1
• PLUS Magnesium Sulfate as above 1

CRITICAL: ACE inhibitors and ARBs are absolutely contraindicated in pregnancy 2

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Template 8: Pheochromocytoma Crisis

Rx: Phentolamine IV (First-Line)

• 5 mg IV bolus 1
• Repeat every 10 minutes as needed to lower BP to target 1

CRITICAL: Alpha-blockade MUST precede beta-blockade to avoid unopposed alpha-mediated vasoconstriction 1

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Template 9: Acute Renal Failure with Hypertensive Emergency

Rx: Clevidipine IV (First-Line)

• Initial: 1-2 mg/hour, double every 90 seconds until BP approaches target 1
• Then increase by less than double every 5-10 minutes; maximum 32 mg/hour 1
• Maximum duration: 72 hours 1

Alternative Rx: Fenoldopam IV

• Initial: 0.1-0.3 mcg/kg/min 1
• Titrate: Increase by 0.05-0.1 mcg/kg/min every 15 minutes to maximum 1.6 mcg/kg/min 1
• Advantage: Improves renal blood flow and causes natriuresis 2

Alternative Rx: Nicardipine IV

• Initial: 5 mg/hour, titrate by 2.5 mg/hour every 5 minutes to maximum 15 mg/hour 2

CRITICAL: Avoid ACE inhibitors in acute renal failure due to risk of precipitous BP drop in volume-depleted patients 2

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Template 10: Perioperative Hypertension

Rx: Clevidipine IV (First-Line)

• Initial: 1-2 mg/hour, double every 90 seconds until BP approaches target 1

Alternative Rx: Esmolol IV

• Loading: 500-1000 mcg/kg over 1 minute, then 50 mcg/kg/min infusion 1

Alternative Rx: Nicardipine IV

• Initial: 5 mg/hour, titrate by 2.5 mg/hour every 5 minutes 2

Alternative Rx: Nitroglycerin IV

• Initial: 5 mcg/min, titrate by 5 mcg/min every 3-5 minutes 2

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HYPERTENSIVE URGENCIES: Oral Prescription Templates

General Principles for ALL Urgencies

Manage as outpatient with oral agents; avoid rapid BP reduction to prevent cardiovascular complications. 2

Blood Pressure Reduction Target:

• Reduce SBP by maximum 25% within first hour → then to <160/100 mmHg over next 2-6 hours 2
• Observe for minimum 2 hours after initiating oral medication to evaluate efficacy and safety 2

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Template 11: Standard Hypertensive Urgency (First-Line Options)

Rx Option A: Captopril PO

• 25 mg PO once 2, 3
• CRITICAL: Start at very low dose due to risk of sudden BP drops in volume-depleted patients 2
• If inadequate response after 1 hour, may give additional 25 mg 3
• Observe for 2 hours minimum 2

Rx Option B: Labetalol PO

• 200-400 mg PO once 2
• Observe for 2 hours minimum 2

Rx Option C: Extended-Release Nifedipine PO

• 30-60 mg PO once (extended-release formulation ONLY) 2
• CRITICAL: NEVER use immediate-release nifedipine—causes uncontrolled BP falls, stroke, and death 2
• Observe for 2 hours minimum 2

Follow-up: Schedule within 24-48 hours to reassess BP and adjust long-term therapy 2

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Template 12: Hypertensive Urgency with Suspected Cocaine/Amphetamine Intoxication

Rx: Benzodiazepine FIRST, then antihypertensive

• Lorazepam: 1-2 mg PO/IV 2
• THEN Labetalol: 200-400 mg PO after sedation achieved 2

CRITICAL: Benzodiazepines should be initiated first for autonomic hyperreactivity 2

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Template 13: Hypertensive Urgency with Coronary Ischemia

Rx: Nitroglycerin SL PLUS Aspirin

• Nitroglycerin: 0.4 mg sublingual every 5 minutes × 3 doses 2
• PLUS Aspirin: 325 mg PO chewed 2
• Transfer to emergency department for further evaluation 2

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Template 14: Medication Non-Adherence (Most Common Cause)

Rx: Reinstitute/Intensify Previous Oral Regimen

• Resume patient's previous antihypertensive regimen at full dose 1, 2
• OR if previously uncontrolled, add second agent from different class 2
• Address adherence barriers: cost, side effects, complexity 2
• Schedule frequent follow-up: at least monthly until target BP reached 2

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Critical Contraindications and Pitfalls

Medications to AVOID in Hypertensive Crises

NEVER use immediate-release nifedipine: Causes rapid, uncontrolled BP falls leading to stroke and death 2, 4, 5

Avoid sodium nitroprusside when possible: Extreme cyanide toxicity risk; reserve for refractory cases only 4, 5

Avoid hydralazine as first-line: Unpredictable antihypertensive effects and difficult BP titration 4, 5

Avoid clonidine in older adults: Significant CNS adverse effects including cognitive impairment 2

Avoid ACE inhibitors in pregnancy: Absolutely contraindicated due to fetal toxicity 2

Special Population Considerations

Volume-depleted patients (malignant hypertension): Start captopril at 6.25-12.5 mg to prevent precipitous BP drop 2, 3

Elderly patients: Use lower initial doses and slower titration; avoid clonidine 2

Renal impairment: Prefer fenoldopam or clevidipine; reduce captopril dose 2, 3

Hepatic impairment: Use nicardipine with caution; monitor closely 6

Clonidine Rebound Hypertension

CRITICAL: Abrupt clonidine discontinuation can induce hypertensive crisis; must taper carefully 2

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Transition from IV to Oral Therapy

Once BP stabilized on IV therapy for 24-48 hours, transition to oral regimen:

• Initiate oral agent 1 hour before discontinuing IV infusion 1
• Overlap therapy to prevent rebound hypertension 1
• Continue ICU monitoring during transition 1