Hypertensive%20crisis Treatment
Principles of Therapy
- 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
Pharmacotherapy
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