What medications should be given to a patient with severe hypertension (blood pressure 190/100) and non-ST elevation myocardial infarction (NSTEMI) on electrocardiogram (ECG)?

Management of NSTEMI with Severe Hypertension (BP 190/100)

For a patient with NSTEMI and blood pressure 190/100, immediately administer sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses, followed by intravenous nitroglycerin for persistent hypertension, and initiate oral beta-blocker therapy within the first 24 hours unless contraindications exist. 1

Immediate Anti-Ischemic Therapy

Nitroglycerin Administration

• Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses for ongoing ischemic discomfort, then assess the need for intravenous nitroglycerin. 1
• Initiate intravenous nitroglycerin within the first 48 hours specifically for treatment of persistent ischemia, heart failure, or hypertension (which applies directly to your patient with BP 190/100). 1
• The decision to administer IV nitroglycerin should not delay other mortality-reducing interventions such as beta blockers or ACE inhibitors. 1

Critical contraindications to avoid: Do not give nitrates if systolic BP <90 mm Hg or ≥30 mm Hg below baseline, severe bradycardia (<50 bpm), tachycardia (>100 bpm) without symptomatic heart failure, right ventricular infarction, or recent phosphodiesterase inhibitor use (sildenafil within 24h, tadalafil within 48h). 1

Beta-Blocker Therapy

• Initiate oral beta-blocker therapy within the first 24 hours for patients without contraindications. 1, 2
• For hypertension specifically, intravenous beta blockers are reasonable at presentation in hemodynamically stable patients, but oral administration is preferred for most NSTEMI patients to reduce mortality without increasing cardiogenic shock risk. 1, 2

Absolute contraindications to beta blockers include: 1, 2

• Signs of heart failure or pulmonary congestion
• Evidence of low-output state
• Increased risk for cardiogenic shock (age >70 years, systolic BP <120 mm Hg, sinus tachycardia >110 or HR <60, prolonged symptom duration)
• PR interval >0.24 seconds
• Second or third-degree heart block
• Active asthma or reactive airway disease

Specific beta-blocker dosing options: 2, 3

• Metoprolol: 50-200 mg twice daily orally (or 5 mg IV boluses × 3 at 2-minute intervals if using IV route, followed by oral dosing)
• Atenolol: 50-200 mg daily
• Bisoprolol: 10 mg daily
• Propranolol: 20-80 mg twice daily

ACE Inhibitor Therapy

• Administer an oral ACE inhibitor within the first 24 hours given the patient's hypertension (BP 190/100), provided systolic BP remains ≥100 mm Hg. 1
• ACE inhibitors are Class I indicated if pulmonary congestion or LVEF ≤0.40 is present. 1
• ACE inhibitors are Class IIa (reasonable) even without pulmonary congestion or reduced LVEF in the setting of hypertension. 1

Critical warning: Do NOT administer intravenous ACE inhibitors within the first 24 hours due to increased hypotension risk; the possible exception is refractory hypertension, but oral administration is still preferred. 1

Alternative Anti-Hypertensive Agents

• If beta blockers are contraindicated, administer a nondihydropyridine calcium channel blocker (verapamil or diltiazem) as initial therapy in the absence of clinically significant LV dysfunction. 1
• Oral long-acting nondihydropyridine calcium channel blockers are reasonable for recurrent ischemia after beta blockers and nitrates have been fully utilized. 1
• Never use immediate-release dihydropyridine calcium channel blockers without adequate beta blockade first, as this is associated with harm. 1

Additional Essential Therapies

Analgesia

• Administer morphine sulfate intravenously if there is uncontrolled ischemic chest discomfort despite nitroglycerin, provided additional therapy addresses the underlying ischemia. 1, 4

Monitoring and Supportive Care

• Place on continuous ECG monitoring with bed/chair rest immediately. 1
• Administer supplemental oxygen only if arterial saturation <90%, respiratory distress is present, or other high-risk features for hypoxemia exist. 1, 4

Antiplatelet and Anticoagulation

While not specifically addressing blood pressure, standard NSTEMI management requires dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) and anticoagulation, which should be initiated concurrently with anti-ischemic therapy. 4, 5

Common Pitfalls to Avoid

• Do not delay oral beta-blocker initiation while attempting to control blood pressure with other agents alone. 2
• Do not routinely use intravenous beta blockers as first-line; oral administration is preferred unless specific indications exist. 2
• Do not withhold nitroglycerin due to elevated blood pressure; it is specifically indicated for hypertension in NSTEMI. 1
• Discontinue all NSAIDs immediately (except aspirin) due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. 1