What is the case presentation for a hypertensive emergency (hypertension crisis)?

From the Guidelines

A hypertensive emergency is characterized by severely elevated blood pressure (typically >180/120 mmHg) with evidence of acute target organ damage, and immediate management involves administering intravenous antihypertensive medications to reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

Key Considerations

• First-line medications include labetalol (20-80 mg IV bolus every 10 minutes or 0.5-2 mg/min infusion), nicardipine (5-15 mg/hr IV infusion), or clevidipine (1-21 mg/hr IV infusion) 1.
• For patients with acute pulmonary edema or heart failure, consider nitroglycerin (5-200 mcg/min IV infusion) 1.
• For aortic dissection, use esmolol (250-500 mcg/kg/min IV bolus, then 50-300 mcg/kg/min infusion) plus a vasodilator 1.
• Continuous cardiac monitoring, frequent vital sign checks, and neurological assessments are essential 1.
• Obtain a comprehensive history, physical examination, and laboratory tests including complete blood count, electrolytes, renal function, cardiac enzymes, urinalysis, and ECG 1.
• Identify and treat underlying causes such as medication non-compliance, renal disease, or endocrine disorders 1.

Treatment Goals

• Reduce blood pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours 1.
• Prevent or limit further hypertensive damage by controlled blood pressure reduction 1.
• Transition to oral antihypertensives and arrange close follow-up within 1-2 weeks after stabilization 1.

Important Considerations

• Rapid but controlled blood pressure reduction is crucial as excessive lowering can lead to cerebral, cardiac, or renal hypoperfusion, while inadequate treatment risks progressive organ damage 1.
• Patients without acute hypertension-mediated organ damage can be treated with oral BP-lowering medication or adaptation of their current BP-lowering medication 1.

From the FDA Drug Label

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. The estimated infusion rate necessary to achieve half of this maximal effect was approximately 10 mg/hour

• Hypertension Emergency Treatment:
  • Nicardipine (IV): Initiate therapy at 5 mg/hr and titrate up to 15 mg/hr as needed 2.
  • Clevidipine (IV): The estimated infusion rate necessary to achieve half of the maximal effect is approximately 10 mg/hour 3.
• Key Considerations:
  • Monitor blood pressure and heart rate closely during infusion.
  • Adjust infusion rate as needed to maintain desired response.
  • Be cautious when titrating in patients with impaired cardiac, hepatic, or renal function.

From the Research

Definition and Presentation of Hypertensive Emergency

• Hypertensive emergency is defined as a systolic blood pressure > 180 mmHg or a diastolic blood pressure > 120 mmHg with evidence of new or progressive end-organ damage 4.
• Approximately 1% of adults in the United States will present with a hypertensive emergency, which can lead to significant morbidity and mortality if not promptly treated 5.
• Hypertensive emergency can present with various symptoms, including severe headache, chest pain, and shortness of breath, and can affect various organs, such as the brain, heart, and kidneys 6.

Treatment Options for Hypertensive Emergency

• Intravenous antihypertensive agents are recommended for the treatment of hypertensive emergencies, including nicardipine, nitroprusside, fenoldopam, nitroglycerin, enalaprilat, hydralazine, labetalol, esmolol, and phentolamine 6.
• Clevidipine is a newer intravenous antihypertensive agent that has been shown to be effective in reducing blood pressure in patients with hypertensive emergencies, with a rapid onset and short duration of action 7.
• The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 6.

Management of Hypertensive Emergency

• Rapid recognition and initiation of therapy are key to minimizing end-organ damage in patients with hypertensive emergency 6.
• The goal of treatment is to rapidly reduce blood pressure to a safe range, while avoiding excessive decreases in blood pressure that can lead to organ hypoperfusion 8.
• Tailoring drug selection according to individual patient characteristics can optimize the management and potential outcomes of patients with hypertensive emergency 6.