What is the best approach for transitioning a patient with hypertensive emergency in the setting of heart failure and acute kidney injury (AKI) from a nitroglycerin drip to oral antihypertensives?

From the Guidelines

When transitioning a patient from a nitroglycerin drip to oral antihypertensives in the setting of hypertensive emergency with heart failure and acute kidney injury (AKI), a careful stepwise approach is recommended, prioritizing the most recent and highest quality study available 1. This approach should begin by gradually reducing the nitroglycerin infusion while simultaneously initiating oral medications. The choice of oral medications should be guided by the need to control blood pressure while addressing the underlying heart failure and protecting renal function.

Key Considerations

• The patient's clinical profile, including the presence of volume overload, cardiac output depression, or other signs of end-organ damage, should guide the selection of oral antihypertensives.
• The use of vasodilators, such as hydralazine, in combination with neurohormonal blockade, including ACE inhibitors or ARBs, and beta-blockers, should be considered to control blood pressure and address heart failure.
• Diuretics, like furosemide, may be necessary to manage fluid overload but require careful monitoring given the AKI.
• Frequent blood pressure monitoring and daily checks of renal function and electrolytes are crucial during the transition.

Transition Protocol

• Gradually reduce the nitroglycerin infusion over 24-48 hours.
• Initiate oral medications, such as hydralazine (10-25 mg every 6 hours) and an ACE inhibitor like lisinopril (2.5-5 mg daily) or an ARB, simultaneously with the reduction of the nitroglycerin infusion.
• Add beta-blockers, such as metoprolol (12.5-25 mg twice daily), once the patient is hemodynamically stable.
• Monitor blood pressure frequently (every 15-30 minutes initially, then hourly, then every 4 hours) and adjust the oral medications as needed to achieve controlled blood pressure reduction.

Rationale

The approach outlined above is based on the most recent and highest quality study available 1, which provides guidance on the management of hypertensive emergencies, including the use of intravenous and oral antihypertensives. By prioritizing controlled blood pressure reduction, addressing the underlying heart failure, and protecting renal function, this approach aims to minimize morbidity, mortality, and improve quality of life for patients with hypertensive emergency and heart failure.

From the Research

Transitioning from Nitroglycerin Drip to Oral Antihypertensives

When transitioning a patient with hypertensive emergency in the setting of heart failure and acute kidney injury (AKI) from a nitroglycerin drip to oral antihypertensives, several factors should be considered:

• The patient's blood pressure should be closely monitored to ensure that it remains within a safe range [ 2 ].
• The use of high-dose nitrates, such as nitroglycerin, has been shown to be effective in reducing blood pressure and improving outcomes in patients with hypertensive acute heart failure [ 2 ].
• However, the transition to oral antihypertensives should be done cautiously to avoid sudden drops in blood pressure, which can worsen AKI [ 3 ].
• The choice of oral antihypertensive agent should be based on the patient's individual needs and medical history, taking into account the presence of heart failure and AKI.

Considerations for Oral Antihypertensive Agents

Some considerations for oral antihypertensive agents in this patient population include:

• The use of agents that are renally dosed, such as ACE inhibitors or ARBs, may require dose adjustments in patients with AKI [ 2 ].
• The use of beta-blockers may be beneficial in patients with heart failure, but may worsen AKI in some cases [ 3 ].
• The use of diuretics may be necessary to manage volume overload in patients with heart failure, but may worsen AKI if not used carefully [ 2 ].

Monitoring and Adjustments

Close monitoring of the patient's blood pressure, renal function, and cardiac status is necessary during the transition from nitroglycerin drip to oral antihypertensives:

• Regular assessment of blood pressure and adjustment of oral antihypertensive agents as needed [ 2 ].
• Monitoring of renal function and adjustment of oral antihypertensive agents as needed to avoid worsening AKI [ 3 ].
• Assessment of cardiac status and adjustment of oral antihypertensive agents as needed to optimize cardiac function [ 2 ].