From the Guidelines
Hypertensive emergency with cardiac involvement and acute kidney injury (AKI) should be treated with labetalol as the first-line medication, given its ability to reduce blood pressure while maintaining cerebral blood flow and not increasing intracranial pressure, as recommended by the European Heart Journal in 2019 1. The treatment approach should prioritize reducing blood pressure by no more than 25% in the first hour, then gradually to 160/100-110 mmHg over the next 2-6 hours.
- Key considerations in managing hypertensive emergency with cardiac involvement and AKI include:
- Using intravenous antihypertensives in an intensive care setting
- Avoiding nitroprusside due to thiocyanate accumulation in AKI
- Carefully managing fluid status to support renal perfusion
- Continuously monitoring cardiac activity, hourly urine output, and frequent electrolyte checks
- Identifying and addressing the underlying cause of hypertension Alternative medications such as nicardipine, esmolol, or nitroglycerin may be used based on specific patient conditions, such as tachycardia or cardiac ischemia, as suggested by the American College of Cardiology in 2018 1.
- The choice of medication should be guided by the patient's comorbidities and the need to minimize target organ damage.
- It is essential to prioritize the patient's morbidity, mortality, and quality of life when making treatment decisions.
- The treatment approach should be individualized to the patient's specific needs and clinical presentation.
From the FDA Drug Label
Monitor closely when titrating nicardipine hydrochloride injection in patients with congestive heart failure or impaired hepatic or renal function [see Warnings and Precautions ( 5-5.4,5-5.5 and 5-5.6)].
The treatment of hypertensive emergency with cardiac involvement and AKI using nicardipine hydrochloride injection requires close monitoring due to the potential for impaired cardiac, hepatic, or renal function.
- Key considerations:
- Titration: Monitor closely when titrating nicardipine hydrochloride injection in these patients.
- Dose adjustment: Adjust the rate of infusion as needed to maintain desired response while minimizing the risk of hypotension or tachycardia.
- Infusion site changes: Change infusion site every 12 hours if administered via peripheral vein. 2
From the Research
Treatment of Hypertensive Emergency with Cardiac Involvement and AKI
- Hypertensive emergencies with cardiac involvement and acute kidney injury (AKI) require immediate attention and treatment to prevent fatal outcomes 3, 4.
- The treatment of hypertensive emergencies involves the use of short-acting titratable intravenous antihypertensive medications, such as labetalol, esmolol, fenoldopam, nicardipine, sodium nitroprusside, and clevidipine 3, 4.
- Nicardipine and nitroprusside have been compared in a prospective study, showing that both are effective in treating hypertensive emergencies, but nicardipine may have a more favorable effect on serum catecholamine levels 5.
- Patients with hypertensive emergencies and AKI have been found to have higher levels of markers of acute and chronic kidney injury, such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C, compared to those with hypertensive urgencies or normotensive controls 6.
- The treatment of hypertensive emergencies with cardiac involvement and AKI should focus on reducing blood pressure gradually, while monitoring renal function and cardiac status closely 3, 7.
- Medications such as hydralazine, immediate release nifedipine, and nitroglycerin should be avoided in the treatment of hypertensive emergencies, except in specific situations such as acute ischemic heart disease complicated by severe hypertension 3, 7.
- Sodium nitroprusside should be used with caution due to its potential toxicity, and alternative agents such as clevidipine may be preferred 4.