From the Guidelines
For a patient with blood pressure that does not go down to 180s, immediate and careful blood pressure lowering with i.v. therapy to <180 mmHg should be considered, especially if the systolic BP is ≥220 mmHg, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. When managing a patient with elevated blood pressure, it is crucial to follow a step-by-step approach to ensure safe and effective blood pressure reduction.
Initial Assessment
- Confirm the elevated reading by taking multiple measurements with proper technique and equipment.
- Assess for underlying causes such as medication non-adherence, pain, anxiety, or secondary hypertension.
Treatment
- Administer a first-line antihypertensive medication such as i.v. labetalol, oral methyldopa, or nifedipine, as recommended by the 2024 ESC guidelines 1.
- Consider intravenous hydralazine as a second-line option.
- Monitor the patient's response every 15-30 minutes and repeat or adjust dosing as needed.
Ongoing Management
- If the initial medication is ineffective, consider adding a second agent with a different mechanism of action.
- Throughout treatment, monitor for signs of end-organ damage including headache, vision changes, chest pain, or neurological deficits.
- Once the blood pressure is stabilized below 180 mmHg, consider transitioning to oral antihypertensive therapy and develop a long-term management plan, taking into account the patient's individual needs and underlying conditions, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 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.
To manage a patient's blood pressure that does not go down to 180s, the following step-by-step approach can be taken:
- Initiate therapy: Start with an infusion rate of 5 mg/hr of nicardipine.
- Monitor and titrate: If the desired blood pressure reduction is not achieved, increase the infusion rate by 2.5 mg/hr every 15 minutes.
- Maximum dose: Do not exceed a maximum infusion rate of 15 mg/hr.
- Rapid reduction: For more rapid blood pressure reduction, titrate the infusion rate every 5 minutes.
- Maintenance: Adjust the rate of infusion as needed to maintain the desired response. 2
From the Research
Step-by-Step Approach for Managing Hypertension
If a patient's blood pressure does not decrease to 180s, the following steps can be taken:
- Assess the patient's current medication regimen and consider adjusting or adding medications as needed 3, 4, 5.
- Consider using a combination of medications, such as nifedipine and captopril, to achieve better blood pressure control 3.
- Monitor the patient's blood pressure closely and adjust the treatment plan as needed to achieve the desired blood pressure goal 6, 7.
- Consider using alternative medications, such as clonidine, which has been shown to be effective in reducing blood pressure in patients with hypertensive urgency 5.
Medication Options
Some medication options that can be considered for managing hypertension include:
- Captopril, an angiotensin-converting enzyme (ACE) inhibitor 3, 4, 5.
- Nifedipine, a calcium channel blocker 3, 6.
- Clonidine, an alpha-2 adrenergic agonist 5.
- Beta blockers, which can be used in combination with ACE inhibitors or angiotensin receptor blockers (ARBs) 7.
- Long-acting nitrates, which can be effective antianginal and anti-ischemic drugs 7.
Blood Pressure Goals
The desired blood pressure goal for patients with hypertension is: