From the Guidelines
The drug of choice in hypertensive emergency is intravenous labetalol, nicardipine, or clevidipine, as recommended by the most recent guidelines 1.
Key Considerations
- The choice of agent depends on the patient's comorbidities, such as asthma, heart block, or acute heart failure.
- Labetalol is typically administered as 20-80 mg IV bolus every 10 minutes or as a continuous infusion at 0.5-2 mg/min.
- Nicardipine is given as a continuous infusion starting at 5 mg/hour, titrated up by 2.5 mg/hour every 5-15 minutes to a maximum of 15 mg/hour.
- Clevidipine is started at 1-2 mg/hour and doubled every 90 seconds until approaching target blood pressure, with a maximum dose of 32 mg/hour.
Treatment Goals
- Reduce mean arterial pressure by no more than 25% within the first hour.
- Achieve a target blood pressure of 160/100-110 mmHg within the next 2-6 hours.
Monitoring and Precautions
- Continuous cardiac monitoring and frequent blood pressure measurements are essential during treatment.
- The specific agent chosen should be based on the patient's comorbidities, such as avoiding labetalol in patients with asthma, heart block, or acute heart failure, and preferring calcium channel blockers like nicardipine in patients with acute stroke or aortic dissection, as supported by the guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Hypertensive Emergency Treatment
The treatment of hypertensive emergencies requires immediate reduction in blood pressure with a titratable, short-acting, intravenous antihypertensive agent 2. The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, and the appropriate therapeutic approach depends on the patient's clinical presentation 2.
Drug Options
Several rapid-acting intravenous antihypertensive agents are available, including:
- Labetalol
- Esmolol
- Fenoldopam
- Nicardipine
- Sodium nitroprusside 2 However, sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 2. Newer agents, such as clevidipine, may hold considerable advantages over other available agents in the management of hypertensive crises 2, 3.
Specific Drug Considerations
- Sodium nitroprusside has the most reliable antihypertensive activity, but should be used with caution in patients with impaired cerebral flow 4.
- Esmolol is effective in controlling both supraventricular tachyarrhythmias and severe hypertension, but should be avoided in patients with low cardiac output 4.
- Nicardipine is a potent arteriolar vasodilator without a significant direct depressant effect on myocardium, but should not be used in patients with severe aortic stenosis 4.
- Clevidipine appears to be a safe and effective alternative to sodium nitroprusside for the management of high blood pressure during acute aortic dissection 5.
Treatment Approach
Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents 2. The choice of agent depends on the patient's clinical presentation and the presence of any underlying medical conditions 4, 6.