Hypertensive%20crisis Treatment

• Primary objectives are to reverse or reduce target organ damage and to begin appropriate antihypertensive therapy
• Assessment of the volume status of the patient is important prior to intravenous (IV) therapy

Treatment Goal

Depending on the clinical situation:

• Reduce the systolic BP (SBP) to no more than 25% in the first hour, then if stable to 160/100-110 mmHg within the next 2-6 hours, then to normal in the next 24-48 hours
  • Avoid excessive reduction in pressure that may result in coronary, cerebral or renal ischemia; exceptions include patients with aortic dissection, pheochromocytoma crisis, severe pre-eclampsia or eclampsia, ischemic stroke, or those who will use thrombolytic agents 
• Alternative is reduction of DBP by 10-15% or to approximately 110 mmHg in 30-60 minutes, with a goal to reduce to normal BP within 24-48 hours

Hypertensive Emergency

• No evidence exists to recommend one agent over another in reducing morbidity or mortality
• Drug of choice is based on individual presentation, comorbidities, contraindications, the presence and type of end-organ damage, the drug’s pharmacology, and the desired rate of BP reduction 

Acute Aortic Dissection

• Preferred treatments: Esmolol, Nitroprusside (with beta-blocker), Nicardipine, Glyceryl trinitrate (GTN), Labetalol
  • Metoprolol can be given as an alternative agent 
• IV antihypertensive treatment should be started as soon as acute aortic dissection is suspected
• Reduce SBP to <120 mmHg and heart rate to <60 beats/minute within the 1st hour 
• Avoid beta-blockers in the presence of aortic valvular regurgitation or suspected cardiac tamponade

Acute Coronary Syndrome

• Preferred treatments: Esmolol with GTN, Labetalol with GTN, Nitroprusside
  • Nitrates lower LV preload and cardiac output and improve coronary blood flow
  • Beta-blockers reduce heart rate, decrease afterload and improve diastolic coronary perfusion
  • Urapidil can be given as an alternative agent
• Give treatment if SBP >160 mmHg and/or DBP >100 mmHg
• Thrombolytics should not be given if BP is >185/100 mmHg

Acute Heart Failure

• Preferred treatments: GTN, Enalapril, Clevidipine
  • Enalapril can reduce afterload thus improving cardiac output
  • Clevidipine decreases peripheral vascular resistance; was shown in a small study to be effective in reducing BP without adverse reactions
•  Use vasodilators + diuretics for SBP ≥140 mmHg; GTN, given IV or sublingually, is preferred

Acute Pulmonary Edema  

• Preferred treatments: Clevidipine, GTN, Nitroprusside
  • Urapidil (with loop diuretic) can be given as an alternative agent for acute cardiogenic pulmonary edema
• Avoid using beta-blockers

Acute Renal Failure/Microangiopathic Anemia

• Preferred treatments: Fenoldopam, Nicardipine, Clevidipine
  • Fenoldopam is a selective dopamine-1 receptor agonist that increases renal perfusion
•  In acute renal insufficiency, mean arterial pressure (MAP) should be reduced by 20-25% within 3-24 hours

Acute Intracerebral Hemorrhage

• Preferred treatments: Labetalol, Nicardipine, Fenoldopam, Esmolol
• In the presence of increased intracranial pressure (ICP), maintain MAP <130 mmHg or SBP <180 mmHg for the 1st 24 hours after onset; avoid reductions in BP to <110 mmHg 
• In the absence of increased ICP, maintain MAP <110 mmHg or SBP <160 mmHg for the 1st 24 hours after onset

Acute Ischemic Stroke

• Preferred treatments: Labetalol, Nicardipine, Fenoldopam, Clevidipine
• Do not give antihypertensive agents unless SBP >220 mmHg or DBP >120 mmHg
  • If DBP is >140 mmHg, Nitroprusside may be given to obtain a 10-15% reduction in 24 hours
• MAP should be reduced by maximum of 15-20% or to DBP not less than 100-110 mmHg within the first 24 hours; however, if patient is receiving fibrinolytic therapy, the goal BP is <185/110 mmHg

Hypertensive Encephalopathy

• Preferred treatments: Labetalol, Nicardipine, Fenoldopam, Clevidipine
• MAP should be reduced by 20-25% or to DBP 100-110 mmHg within the first hour then gradual reduction in BP within normal range over 48-72 hours

Subarachnoid Hemorrhage

• Preferred treatments: Labetalol, Nicardipine or Esmolol
• SBP should be maintained <160 mmHg until aneurysm is treated or cerebral vasospasm occurs

Adrenergic Crisis

• Hyperadrenergic states include sympathomimetic drug use (eg cocaine, amphetamines, Phenylpropanolamine, combination of MAOIs with tyramine-rich foods), pheochromocytoma or after sudden discontinuation of a short-acting sympathetic blocker 
• Preferred treatments for pheochromocytoma: Phentolamine, Labetalol with Nitroprusside, Urapidil
  • SBP should be reduced to <140 mmHg within the 1st hour of therapy
• Preferred treatments for sympathetic crisis related to use of sympathomimetic drugs: Benzodiazepines, Phentolamine, Labetalol with Nitroprusside, Verapamil, Diltiazem, Nicardipine in combination with Benzodiazepine, Clonidine
• Alpha-blockers are preferred agents
  • Avoid selective beta-blockers which can worsen hypertension

Severe Pre-eclampsia or Eclampsia

• Preferred treatments: Labetalol, Hydralazine, Nicardipine
• Avoid Nitroprusside, ACE inhibitors, ARBs, renin inhibitors, and Esmolol
• SBP should be reduced to <140 mmHg within the 1st hour of therapy
  • SBP >160 mmHg has been associated with cerebrovascular accidents
•  Magnesium sulfate should be given to prevent seizures

Acute Postoperative Hypertension

• Preferred treatments: Labetalol, Nicardipine, Clevidipine, Esmolol, Urapidil
• Treatment is indicated in cardiac surgery patients with a BP>140/90 mmHg or a MAP of at least 105 mmHg

Hypertensive Urgency

The term “hypertensive urgency” has led to overly aggressive management of many patients

• Reduce BP to 160/100 mmHg over hours to days
• Reduction of BP in these patients may be achieved with short-acting oral medications and without intensive monitoring
• No consensus exists stating that initiating treatment in the ED is cost-effective and improves long-term patient care
• Please see Hypertension disease management chart for full dosage guidelines of the following oral agents

Captopril

• Considered 1st-line agent
• Onset of action is within 30-60 minutes
• Co-administration of a loop diuretic enhances the effect of this drug
• Avoid in patients with high-grade bilateral renal artery stenosis
• Please see Hypertension disease management chart for dosage guidelines of diuretics

Clonidine

• Onset of action is within 30-60 minutes
• Avoid in patients requiring mental status monitoring

Labetalol

• Onset of action is within 20-120 minutes
• Avoid in patients with asthma as this may worsen bronchospasm
• Use with caution in patients with symptomatic bradycardia, congestive heart failure and heart block

Nifedipine (extended-release)

• Onset of action is within 30 minutes
• Avoid the use of short-acting oral or sublingual Nifedipine due to risk of stroke, AMI and severe hypotension

Amlodipine

• Onset of action is within 30-50 minutes

Prazosin

• Onset of action is within 2-4 hours
• May cause postural hypotension and syncope with 1st dose