From the Guidelines
Labetalol is the medication of choice for lowering blood pressure in a hypertensive emergency.
Key Considerations
- The goal is to reduce mean arterial pressure by 20-25% in cases like malignant hypertension, hypertensive encephalopathy, and acute haemorrhagic stroke, and by 15% in cases like acute ischaemic stroke, as stated in the European Heart Journal study 1.
- Labetalol is preferred in certain situations, such as hypertensive encephalopathy, because it leaves cerebral blood flow relatively intact and does not increase intracranial pressure, as noted in the study 1.
- Other options like Nitroprusside, Nicardipine, and Urapidil can be used as alternatives, depending on the specific clinical presentation, as outlined in Table 3 of the study 1.
- The administration of these medications should be carefully titrated to achieve the desired blood pressure reduction, while avoiding excessive or too rapid blood pressure lowering, as cautioned in the study 1.
- In some cases, such as acute aortic disease, Esmolol and Nitroprusside or Nitroglycerine may be preferred to achieve a systolic blood pressure <120 mmHg and heart rate <60 b.p.m., as stated in the study 1.
From the FDA Drug Label
Sodium nitroprusside is indicated for the immediate reduction of blood pressure of adult and pediatric patients in hypertensive crises. The medication of choice for lowering blood pressure in a hypertensive emergency is sodium nitroprusside (IV), as it is specifically indicated for the immediate reduction of blood pressure in hypertensive crises 2.
- Key points:
- Immediate reduction of blood pressure
- Indicated for hypertensive crises
- Administered intravenously (IV) Note that nicardipine (IV) is also used to treat hypertension, but the label does not specifically indicate its use in hypertensive emergencies, rather in mild-to-moderate chronic stable essential hypertension or severe or postoperative hypertension 3.
From the Research
Medication for Hypertensive Emergency
The medication of choice for lowering blood pressure in a hypertensive emergency is typically an intravenous agent that can be titrated to achieve a controlled reduction in blood pressure. Some of the commonly used medications include:
- Sodium nitroprusside 4, 5, 6, 7
- Nitroglycerin 4, 5, 6, 8
- Labetalol 4, 5, 6, 8
- Hydralazine 4, 5, 6, 8
- Enalaprilat 4, 8
- Nicardipine 6, 8
- Fenoldopam 6, 8
- Phentolamine 4, 5, 8
- Esmolol 6, 8
- Clevidipine 8
Factors Influencing Medication Choice
The choice of medication depends on various factors, including:
- The presence of end-organ damage 4, 5, 6, 7, 8
- The patient's comorbidities 8
- The need for rapid blood pressure reduction 5, 6, 7, 8
- The potential for adverse effects 4, 5, 6, 7, 8
Goal of Treatment
The goal of treatment in hypertensive emergency is to reduce the mean arterial pressure by 10% to 25% over the initial 2 to 4 hours, with a further reduction of 10% to 15% over the next 2 to 4 hours 4, 6, 7. The aim is to prevent or minimize end-organ damage while avoiding excessive reduction in blood pressure that can lead to hypoperfusion 6, 7.