What is the treatment for hypertensive emergency (severe hypertension)?

From the Guidelines

Hypertensive emergency requires immediate treatment with intravenous antihypertensive agents to reduce blood pressure and prevent end-organ damage, with the goal of lowering mean arterial pressure by no more than 25% within the first hour, then to 160/100-110 mmHg within the next 2-6 hours, and normalize over 24-48 hours, as recommended by the most recent guidelines 1. The treatment approach should be individualized based on the presence of comorbidities and the type of acute organ damage, with the selection of an antihypertensive agent based on its pharmacology, pathophysiological factors underlying the patient’s hypertension, degree of progression of target organ damage, and the desirable rate of BP decline 1. Some key considerations for specific conditions include:

• Acute aortic dissection: esmolol or labetalol to rapidly lower SBP to ≤120 mm Hg within 20 minutes 1
• Acute pulmonary edema: clevidipine, nitroglycerin, or nitroprusside, with beta blockers contraindicated 1
• Acute coronary syndromes: esmolol, labetalol, nicardipine, or nitroglycerin, with consideration of contraindications to beta blockers 1
• Eclampsia or preeclampsia: hydralazine, labetalol, or nicardipine, with rapid BP lowering required and ACE inhibitors, ARBs, renin inhibitors, and nitroprusside contraindicated 1 Patients require continuous cardiac monitoring, frequent vital sign checks, and assessment of neurological status, renal function, and electrolytes, with careful titration of antihypertensive agents to avoid cerebral hypoperfusion 1. After stabilization, transition to oral antihypertensives and investigate underlying causes such as medication non-adherence, renal artery stenosis, pheochromocytoma, or primary aldosteronism to prevent recurrence, as recommended by the European Heart Journal 1.

From the FDA Drug Label

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. For more rapid blood pressure reduction, titrate every 5 minutes.

Treatment of Hypertensive Emergency with Nicardipine:

• Initiate therapy at 5 mg/hr and titrate as needed to achieve desired blood pressure reduction.
• The maximum infusion rate is 15 mg/hr.
• Monitor patients closely, especially those with impaired cardiac, hepatic, or renal function 2.

Following discontinuation of intravenous treatment with labetalol HCl, the blood pressure rose gradually and progressively, approaching pretreatment baseline values within an average of 16 to 18 hours in the majority of patients Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg

Treatment of Hypertensive Emergency with Labetalol:

• Initial dose: 0.25 mg/kg or 20 mg, followed by additional doses of 40 or 80 mg at 10-minute intervals as needed.
• Continuous intravenous infusion: mean dose of 136 mg over 2-3 hours.
• Monitor patients closely, especially when discontinuing therapy, due to the risk of rebound hypertension 3.

From the Research

Definition and Classification of Hypertensive Emergency

• Hypertensive crises are categorized as either hypertensive emergencies or urgencies, depending on the presence of acute end-organ damage 4, 5, 6, 7, 8.
• Hypertensive emergency is a condition where there is elevation of both systolic and diastolic blood pressure with the presence of acute target organ disease, such as stroke, myocardial infarction, or heart failure 7, 8.
• Hypertensive urgency is a condition where the blood pressure is elevated without signs or symptoms of acute hypertensive target organ damage 7, 8.

Treatment of Hypertensive Emergency

• Immediate reduction in blood pressure is required in patients with acute end-organ damage (i.e., hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent 4, 5, 6.
• Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents 4, 8.
• Rapid-acting intravenous antihypertensive agents available for treatment include labetalol, esmolol, fenoldopam, nicardipine, and clevidipine 4, 6, 7.
• Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided 4, 6.
• Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages over other available agents in the management of hypertensive crises 4, 6.

Treatment of Hypertensive Urgency

• Hypertensive urgencies can usually be managed with oral agents, such as nifedipine, captopril, clonidine, labetalol, prazosin, and nimodipine 7.
• Blood pressure should be lowered within 24 to 48 hours in order to avoid hypertensive target organ damage 8.
• Hospitalization is not usually required, and oral antihypertensive therapy is usually sufficient 8.