From the Guidelines
For a patient with a blood pressure of 171/105 mmHg, immediate intervention is necessary as this represents stage 2 hypertension, but according to the most recent guidelines, this does not necessarily constitute a hypertensive emergency unless accompanied by acute organ damage 1. The patient should be evaluated for signs of acute organ damage such as severe headache, vision changes, chest pain, or shortness of breath, which may indicate a hypertensive emergency requiring immediate medical attention and intravenous therapy 1. If no acute organ damage is present, the patient can be treated with oral antihypertensive therapy, starting with lifestyle modifications including sodium restriction, regular physical activity, weight loss if overweight, limiting alcohol consumption, and adopting the DASH diet, alongside initiation of two-drug combination therapy, typically a long-acting calcium channel blocker plus an ACE inhibitor or ARB 1. Key considerations include:
- The choice of antihypertensive treatment is predominantly determined by the type of organ damage, if present 1.
- Patients with substantially elevated BP who lack acute hypertension-mediated end organ damage can typically be treated with oral antihypertensive therapy and usually discharged after a brief period of observation 1.
- Home blood pressure monitoring is recommended, with a target of <130/80 mmHg, and follow-up within 2-4 weeks to assess treatment response and adjust medications if needed 1. Given the most recent and highest quality study available, the approach should prioritize assessing for acute organ damage and then tailoring treatment accordingly, with a focus on oral therapy for those without hypertensive emergencies 1.
From the FDA Drug Label
Titration 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.
For a patient with a blood pressure of 171/105, initiate therapy with nicardipine (IV) at a rate of 5 mg/hr. If the desired blood pressure reduction is not achieved, increase the infusion rate by 2.5 mg/hr every 15 minutes, up to a maximum of 15 mg/hr, until the desired blood pressure reduction is achieved. Alternatively, for more rapid blood pressure reduction, titrate every 5 minutes. 2
From the Research
Management of Hypertensive Crises
- Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage, and are best treated with intravenous titratable agents 3.
- For a patient with a blood pressure of 171/105, it is essential to determine whether they are experiencing a hypertensive emergency or urgency, as this will guide the treatment approach.
Treatment Options
- Nicardipine and labetalol are two intravenous antihypertensive agents that can be used to manage hypertensive crises, with comparable efficacy and safety profiles 3, 4.
- Nicardipine may provide more predictable and consistent BP control than labetalol 3.
- Continuous-infusion labetalol and nicardipine have been compared in stroke patients, with no significant difference in time at goal BP, rescue antihypertensive use, or BP variability 4.
Considerations for Treatment
- The choice of antihypertensive agent may depend on the specific clinical context, including the presence of end-organ damage, the severity of hypertension, and the patient's medical history.
- It is crucial to closely monitor the patient's blood pressure and adjust the treatment as needed to achieve a safe and effective blood pressure reduction.