When should hypertension be treated in the prehospital (emergency medical services) setting?

From the Guidelines

Hypertension in the prehospital setting should only be treated when it presents as a hypertensive emergency, characterized by severely elevated blood pressure (typically >180/120 mmHg) with evidence of acute end-organ damage, as stated in the 2024 ESC guidelines 1.

Key Considerations

• The goal of treatment is not to normalize blood pressure but to reduce it gradually by about 20-25% within the first hour, as recommended by the European Heart Journal 1.
• First-line medications in the prehospital setting typically include labetalol, nitroglycerin, or nicardipine, with specific dosing and titration guidelines outlined in the European Heart Journal 1.
• It's crucial to monitor the patient continuously during treatment, as rapid blood pressure reduction can cause cerebral hypoperfusion, ischemia, or infarction, as noted in the Journal of the American College of Cardiology 1.

Treatment Focus

• Treatment should focus on patients showing signs of hypertensive encephalopathy, acute coronary syndrome, acute heart failure, aortic dissection, or stroke, as defined in the European Heart Journal 1.
• Asymptomatic hypertension, even if severely elevated, generally should not be aggressively treated in the prehospital setting, as this could lead to harm without providing benefit, as stated in the Circulation journal 1.

Underlying Principle

• The underlying principle is that chronic hypertension has caused autoregulatory adaptations in blood flow, making rapid decreases potentially dangerous, as discussed in the European Heart Journal 1.

From the FDA Drug Label

When treating acute hypertensive episodes in patients with chronic hypertension, discontinuation of infusion is followed by a 50% offset of action in 30 minutes ± 7 minutes but plasma levels of drug and gradually decreasing antihypertensive effects exist for many hours.

The decision of when to treat hypertension prehospital is not directly addressed in the provided drug label. However, it can be inferred that hypertension should be treated when it presents as an acute hypertensive episode, especially in patients with chronic hypertension.

• The timing of treatment is not explicitly stated, but it is implied that treatment should be initiated when blood pressure reduction is necessary to prevent complications.
• Titration of the infusion rate may be necessary to achieve the desired blood pressure reduction, and the rate of infusion should be adjusted as needed to maintain the desired response.
• It is essential to monitor closely when titrating nicardipine hydrochloride injection in patients with impaired cardiac, hepatic, or renal function 2.

From the Research

Hypertension Treatment

Hypertension should be treated prehospital in cases of hypertensive emergencies, which are acute elevations in blood pressure that occur in the presence of progressive end-organ damage 3.

Indications for Treatment

• Hypertensive emergencies, such as those with acute end-organ damage, require immediate treatment with intravenous titratable agents 3, 4.
• Severe asymptomatic hypertension, defined as a systolic blood pressure of 180 mm Hg or greater, or diastolic blood pressure of 110 mm Hg or greater, without signs or symptoms of end-organ damage, may not require immediate treatment but should be evaluated and treated based on the patient's cardiovascular risk profile 4.

Treatment Options

• Intravenous labetalol and nicardipine are commonly used to treat hypertensive crises, with nicardipine appearing to provide more predictable and consistent blood pressure control than labetalol 3, 5.
• Intravenous nitroglycerin is also used to treat hypertensive crises, but labetalol may control blood pressure more rapidly without causing extra side effects 6.

Patient Considerations

• Patients with renal dysfunction may benefit from treatment with nicardipine, which has been shown to be more efficacious than labetalol in achieving target blood pressure range within 30 minutes 5.
• The choice of treatment should be guided by the patient's individual needs and medical history, with consideration of the potential benefits and risks of each treatment option 3, 4, 6, 5.