From the Guidelines
Hypertensive crisis management involves prompt initiation of antihypertensive therapy to reduce blood pressure and prevent target organ damage.
Key Principles
- For patients with severe hypertension and compelling conditions (e.g., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), 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.
- For patients without compelling conditions, systolic blood pressure (SBP) should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours 1.
Treatment Options
- Intravenous administration of nicardipine (5-15 mg/hour) or clevidipine (1-21 mg/hour) is recommended, with titration to achieve a blood pressure reduction of 10-15% within the first hour 1.
- Alternatively, intravenous labetalol (20-80 mg bolus, followed by 0.5-2 mg/minute infusion) or sodium nitroprusside (0.25-1.5 mcg/kg/minute) may be used, with close monitoring of blood pressure and clinical status 1.
- Oral medications such as clonidine (0.1-0.2 mg) or captopril (6.25-12.5 mg) may be considered for less severe cases 1.
Monitoring and Management
- Patients with hypertensive emergencies should be admitted to an intensive care unit for continuous monitoring of blood pressure and target organ damage 1.
- The choice of antihypertensive treatment is predominantly determined by the type of organ damage 1.
- Rapid blood pressure lowering is required in patients with pulmonary edema and acute aortic dissection, whereas blood pressure-lowering medication is generally withheld in patients with ischemic stroke 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. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. 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.
The management of Hypertensive (Htn) crisis involves the use of intravenous medications such as sodium nitroprusside and nicardipine.
- Sodium nitroprusside is indicated for the immediate reduction of blood pressure in hypertensive crises 2.
- Nicardipine can be administered by slow continuous infusion at a concentration of 0.1 mg/mL, with a starting dose of 5 mg/hr and titrated up to a maximum of 15 mg/hr as needed 3. Key points to consider when managing hypertensive crisis include:
- Close monitoring of blood pressure and heart rate
- Adjustment of infusion rates as needed to maintain desired response
- Consideration of concomitant longer-acting antihypertensive medication to minimize the duration of treatment with intravenous medications.
From the Research
Management of Hypertensive Crisis
The management of hypertensive crisis involves the prompt recognition of the condition and the appropriate reduction of blood pressure to prevent end-organ damage. The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 4, 5, 6, 7.
Classification of Hypertensive Crisis
Hypertensive crises are categorized as either hypertensive emergencies or urgencies, depending on the degree of blood pressure elevation and presence of end-organ damage 4, 5, 6, 7.
- Hypertensive emergencies: characterized by acute end-organ damage, requiring immediate reduction of blood pressure with intravenous antihypertensive agents 4, 5, 6, 7.
- Hypertensive urgencies: characterized by severe hypertension without acute end-organ damage, usually treated with oral antihypertensive agents 4, 5, 6, 7.
Treatment of Hypertensive Emergencies
Patients with hypertensive emergencies are best treated in an intensive care unit with titratable intravenous hypotensive agents 4, 5, 6, 7.
- Rapid-acting intravenous antihypertensive agents available include:
- Newer agents, such as clevidipine, may hold considerable advantages over other available agents in the management of hypertensive crises 4, 7.
Treatment of Hypertensive Urgencies
Patients with hypertensive urgencies can usually be treated with oral antihypertensive agents as outpatients 4, 5, 6, 7.
- Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy in patients with hypertensive emergencies 6.
Important Considerations
- Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 4, 5, 7.
- Nifedipine, nitroglycerin, and hydralazine should not be considered first-line therapies in the management of hypertensive crises due to significant toxicities and/or adverse effects 4, 5, 7.