From the Guidelines
Labetalol is the preferred medication for hypertensive crisis in hypertensive emergency (HCOM) in the emergency department, as it provides both alpha and beta blockade, resulting in decreased peripheral vascular resistance without significant reduction in cardiac output or heart rate 1. It can be administered as an IV bolus of 20 mg initially, followed by 20-80 mg every 10 minutes as needed, up to a maximum dose of 300 mg. Alternatively, an IV infusion can be started at 1-2 mg/min and titrated to the desired blood pressure.
Key Considerations
- Other suitable options include nicardipine (initial dose 5 mg/hr IV, increased by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr) and clevidipine (1-2 mg/hr IV initially, doubled every 90 seconds until approaching target BP, then increased by smaller increments) 1.
- These medications allow for rapid titration, have short half-lives for quick offset if blood pressure drops too low, and can be administered in a controlled manner to gradually lower blood pressure by approximately 25% in the first hour, avoiding the risks associated with sudden drops in pressure.
- The choice between these agents may depend on specific patient factors such as comorbidities, the underlying cause of hypertension, and contraindications to specific medications 1.
Patient Factors to Consider
- Comorbidities: certain medications may be contraindicated in patients with specific comorbidities, such as asthma or heart failure 1.
- Underlying cause of hypertension: the choice of medication may depend on the underlying cause of hypertension, such as pheochromocytoma or eclampsia 1.
- Contraindications: certain medications may be contraindicated in patients with specific conditions, such as pregnancy or liver disease 1.
From the FDA Drug Label
1 INDICATIONS & USAGE
1.1 Hypertension Nicardipine hydrochloride injection is indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable.
The blood pressure medication of choice for hypertensive emergency in the emergency department is nicardipine (IV), as it is indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable 2.
From the Research
Hypertensive Emergencies in the Emergency Department
The management of hypertensive emergencies in the emergency department requires immediate attention with intravenous antihypertensive medications. The choice of medication depends on the type of end-organ damage, pharmacokinetics, and comorbidities 3.
Medication Options
Some of the commonly used medications for hypertensive emergencies include:
- Sodium nitroprusside (SNP), which has reliable antihypertensive activity but should be used with caution in patients with impaired cerebral flow 4, 5
- Nicardipine, a potent arteriolar vasodilator without a significant direct depressant effect on the myocardium, which is useful in patients with severe hypertension but should not be used in patients with severe aortic stenosis 4, 5, 6
- Fenoldopam, a selective post-synaptic dopaminergic receptor (DA1) agonist, which has been shown to be effective in treating severe hypertension with a lower incidence of side effects than SNP 4, 5
- Clevidipine, a third-generation dihydropyridine calcium-channel blocker, which has been shown to reduce mortality when compared with nitroprusside 5
- Esmolol, which is effective in controlling both supraventricular tachyarrhythmias and severe hypertension but should be avoided in patients with low cardiac output 4
Comparison of Medications
A study comparing the efficacy and safety of nicardipine and clevidipine for blood pressure control in hypertensive crisis found that nicardipine achieved a systolic blood pressure goal of <160 mm Hg at 2-6 h significantly more often than the clevidipine group 6.
Treatment Approach
The treatment approach for hypertensive emergencies involves the use of short-acting, easily titratable, intravenous antihypertensive medications, with the goal of reducing blood pressure in a controlled manner to prevent end-organ damage 7, 3.