From the Guidelines
Managing Hypertensive Urgency and Emergency
Hypertensive urgency and emergency are managed differently, with hypertensive urgency typically involving oral medications to reduce systolic blood pressure by 10-15% within the first hour, and hypertensive emergency requiring immediate intravenous therapy to reduce blood pressure and prevent target organ damage 1, 2, 3, 4, 5, 6.
Key Recommendations
- For hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of blood pressure and target organ damage, with parenteral administration of an appropriate agent 1, 2, 3, 4.
- For adults with a compelling condition (e.g., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), systolic blood pressure should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection 1, 2, 3, 4.
- For adults without a compelling condition, systolic blood pressure should be reduced by no more than 25% within the first hour, then to 160/100 mm Hg within the next 2 to 6 hours, and cautiously to normal during the following 24 to 48 hours 1, 2, 3, 4.
Treatment Options
- Oral medications such as clonidine or captopril may be used for hypertensive urgency, with the goal of reducing systolic blood pressure by 10-15% within the first hour 5, 6.
- Intravenous therapy with agents such as sodium nitroprusside or nicardipine is recommended for hypertensive emergency, with close monitoring of blood pressure and clinical status 1, 2, 3, 4, 6.
Important Considerations
- Rapid blood pressure reduction is not recommended for patients without acute hypertension-mediated organ damage, as it can lead to cardiovascular complications 6.
- Close monitoring of blood pressure and clinical status is essential for patients with hypertensive emergency, to prevent or limit further target organ damage 1, 2, 3, 4, 6.
From the FDA Drug Label
Nicardipine hydrochloride injection is indicated for the short-term treatment of hypertension when oral therapy is not feasible or desirable. The FDA drug label does not answer the question.
From the Research
New Guidelines for Managing Hypertensive Urgency and Hypertensive Emergency
The management of hypertensive urgency and hypertensive emergency involves the use of various medications to safely reduce blood pressure. The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure, with immediate reduction required only in patients with acute end-organ damage (i.e., hypertensive emergency) 7, 8, 9.
Classification of Hypertensive Crises
Hypertensive crises are categorized as either hypertensive emergencies or urgencies, depending on the degree of blood pressure elevation and presence of end-organ damage. Hypertensive emergencies are characterized by acute end-organ damage, while hypertensive urgencies are defined as severe hypertension without acute end-organ damage 7, 8, 9.
Treatment of Hypertensive Emergencies
Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents. Rapid-acting intravenous antihypertensive agents are available, including:
- Labetalol
- Esmolol
- Fenoldopam
- Nicardipine
- Clevidipine Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 7, 8, 9.
Treatment of Hypertensive Urgencies
Hypertensive urgencies can usually be managed with oral agents, including:
- Nifedipine
- Captopril
- Clonidine
- Labetalol
- Prazosin
- Nimodipine However, intravenous medications may also be used in hospitalized patients without organ dysfunction, and have been shown to decrease blood pressure more rapidly than oral medications 10.
Key Considerations
- The use of intravenous medications in hospitalized hypertensive patients without organ dysfunction is common, and is associated with higher comorbidity burden and longer length of stay 10.
- Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided due to their significant toxicities and/or side effects 7, 8, 9.
- The risk factors and prognosticators of a hypertensive crisis are still under recognized, and physicians should perform complete evaluations in patients who present with a hypertensive crisis to effectively reverse, intervene, and correct the underlying trigger 8.