What is the management of a hypertensive emergency?

From the Guidelines

A hypertensive emergency is a severe elevation in blood pressure (typically >180/120 mmHg) with evidence of acute end-organ damage requiring immediate treatment, and management begins with prompt administration of intravenous antihypertensive medications in a monitored setting, typically an ICU, with the goal of reducing mean arterial pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and to normal over 24-48 hours, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.

The first-line medications for hypertensive emergencies include nicardipine, labetalol, or clevidipine, with the specific medication choice guided by the affected organ system, such as using labetalol or esmolol for aortic dissection, avoiding beta-blockers in heart failure, and using nicardipine for stroke 1.

Some key points to consider in the management of hypertensive emergencies include:

• The importance of prompt treatment in a monitored setting to prevent further target organ damage 1
• The need to reduce mean arterial pressure by no more than 25% within the first hour to avoid cerebral, cardiac, or renal hypoperfusion 1
• The use of intravenous antihypertensive medications, with oral antihypertensives introduced once the patient is stabilized 1
• The importance of close follow-up to ensure long-term blood pressure control and prevent recurrence 1

It is also important to note that the specific organ system affected should guide medication choice, and that the goal of treatment is to minimize target organ damage safely by rapid recognition of the problem and early initiation of appropriate antihypertensive treatment 1.

In terms of specific medication dosing, the following can be considered:

• Nicardipine: initial dose 5 mg/hr, titrated by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr 1
• Labetalol: 20-80 mg bolus every 10 minutes or 0.5-2 mg/min infusion 1
• Clevidipine: 1-2 mg/hr initially, doubled every 90 seconds until approaching target, maximum 32 mg/hr 1

Overall, the management of hypertensive emergencies requires prompt and careful treatment to prevent further target organ damage and improve patient outcomes, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 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. In a clinical pharmacologic study in severe hypertensives, an initial 0. 25 mg/kg injection of labetalol HCl, administered to patients in the supine position, decreased blood pressure by an average of 11/7 mmHg. Additional injections of 0.5 mg/kg at 15-minute intervals up to a total cumulative dose of 1.75 mg/kg of labetalol HCl caused further dose-related decreases in blood pressure.

Hypertensive Emergency Treatment:

• Nicardipine (IV): Initiate therapy at 5 mg/hr and titrate every 15 minutes by 2.5 mg/hr up to a maximum of 15 mg/hr for gradual reduction, or every 5 minutes for more rapid reduction 2.
• Labetalol (IV): Initial dose of 0.25 mg/kg, followed by additional doses of 0.5 mg/kg at 15-minute intervals, up to a total cumulative dose of 1.75 mg/kg 3.

From the Research

Definition and Classification of Hypertensive Emergency

• Hypertensive emergency is a condition characterized by elevated blood pressure with the presence of acute target organ disease 4, 5, 6.
• It is estimated that approximately 1% of patients with hypertension will develop a hypertensive crisis, which can be further classified as either hypertensive emergencies or urgencies 4.

Treatment of Hypertensive Emergency

• Immediate reduction in blood pressure is required in patients with acute end-organ damage, and treatment with a titratable, short-acting, intravenous antihypertensive agent is necessary 4, 5, 7.
• Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents 4.
• Rapid-acting intravenous antihypertensive agents available for treatment include labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside 4, 5, 7.
• Newer agents, such as clevidipine, may hold considerable advantages over other available agents in the management of hypertensive crises 4, 8.

Medications to Avoid in Hypertensive Emergency

• Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided due to its potential adverse effects 4, 5, 8.
• Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to their significant toxicities and/or adverse effects 4, 5, 8.

Importance of Appropriate Management

• Appropriate identification, evaluation, and treatment of hypertensive emergencies are crucial to prevent progression of organ damage and death 6.
• A thorough knowledge of the pharmacological properties and proper indications of the currently used agents is essential for optimum management of the critically ill hypertensive patient 7.