Principles of Therapy
The primary objectives of therapy are to reverse or reduce target organ damage and to begin appropriate IV antihypertensive therapy. Check whether the affected organs require any specific intervention and if the patient is pregnant, as this may affect the treatment plan. For adult patients presenting with hypertensive emergency in the primary care setting who are awaiting transfer, initiate IV antihypertensive therapy (oral if IV access is unavailable) and promptly refer to a health facility equipped to monitor and safely manage BP reduction. Assessment of the volume status of the patient is important prior to IV therapy. IV therapy with a drug that has a short half-life allows careful dose titration based on the patient’s BP response. Low initial doses with cautious dose uptitration should be used.
Treatment Goal
The treatment goal depends on the clinical situation of the patient. In patients without a compelling condition, reduce the 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 cautiously to 130-140 mmHg in the next 24-48 hours to limit target organ injury. Avoid excessive reduction in pressure that may result in coronary, cerebral, or renal ischemia; exceptions to gradual lowering of BP over the first day include patients with acute aortic dissection, severe preeclampsia or eclampsia, intracerebral hemorrhage, ischemic stroke, or those who will use thrombolytic agents. SBP should be reduced to <120 mmHg in aortic dissection and to <140 mmHg for most conditions, including pheochromocytoma crisis, during the first hour while monitoring other target organ damage. The alternative is the 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. Once BP control is at target in the intensive care unit (ICU), initial IV therapy is tapered and discontinued, and oral medications are started.
Pharmacological therapy
Hypertensive Emergency
Hypertensive Crisis_Management 1Preferred Antihypertensive Agents for Select Hypertensive Emergencies1
No evidence exists to recommend one agent over another in reducing morbidity or mortality. The 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.
1Recommendations for preferred antihypertensive agents may vary between countries. Please refer to available guidelines from local health authorities.
Acute Aortic Dissection
Preferred treatments: Esmolol, Glyceryl trinitrate (GTN), Nicardipine, Nitroprusside (with beta-blocker)
Labetalol or Metoprolol can be given as an alternative agent. These reduce SBP to <120 mmHg and heart rate to <60 beats/minute within the first hour. IV antihypertensive treatment should be started as soon as acute aortic dissection is suspected. Avoid beta-blockers in the presence of aortic valvular regurgitation or suspected cardiac tamponade. Initiate beta-blockade before vasodilator therapy (eg Nicardipine or Nitroprusside) to avoid reflex tachycardia or inotropic effects.
Acute Coronary Syndrome
Hypertensive Crisis_Management 2Preferred treatments: Clevidipine, Esmolol with GTN, Labetalol with GTN, Nicardipine, 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. Contraindications to beta blockers include moderate-to-severe LV failure with pulmonary edema, heart rate <60 beats/min, SBP <100 mmHg, poor peripheral perfusion, second- or third-degree heart block, and reactive airways disease. Urapidil can be given as an alternative agent. Give treatment if SBP >160 mmHg and/or DBP >100 mmHg; reduce SBP to <140 mmHg. Thrombolytics should not be given if BP is >185/100 mmHg.
Acute Heart Failure
Preferred treatments: Clevidipine, Enalapril, Glyceryl trinitrate
Enalapril can reduce afterload, thus improving cardiac output. Clevidipine decreases peripheral vascular resistance; it was shown in a small study to be effective in reducing BP without adverse reactions. Reduce BP to <25% within 1 hour, then ≤160/100 mmHg over 2-6 hours. Use vasodilators and diuretics for SBP ≥140 mmHg; GTN, given IV or sublingually, is preferred.
Acute Pulmonary Edema
Preferred treatments: Clevidipine, Glyceryl trinitrate, Nitroprusside
Urapidil (with loop diuretic) can be given as an alternative agent for acute cardiogenic pulmonary edema. Reduce SBP to <140 mmHg. Avoid using beta-blockers.
Acute Renal Failure/Microangiopathic Anemia
Hypertensive Crisis_Management 3Preferred treatments: Clevidipine, Fenoldopam, Labetalol, Nicardipine
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: Clevidipine, Esmolol, Fenoldopam, Hydralazine, Labetalol, Nicardipine
In the presence of increased intracranial pressure (ICP), maintain MAP <130 mmHg or SBP <180 mmHg for the first 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 first 24 hours after onset.
Acute Ischemic Stroke
Preferred treatments: Clevidipine, Esmolol, Fenoldopam, Hydralazine, Labetalol, Nicardipine
Mean arterial pressure (MAP) should be reduced by a maximum of 15-20% or to DBP not less than 100-110 mmHg within the first 24 hours; however, if the patient is receiving fibrinolytic therapy, the goal BP is <185/110 mmHg. 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.
Hypertensive Encephalopathy
Hypertensive Crisis_Management 4Preferred treatments: Clevidipine, Fenoldopam, Labetalol, Nicardipine, Nitroprusside
Mean arterial pressure (MAP) should be reduced by 20-25% or to DBP 100-110 mmHg within the first hour, then a gradual reduction in BP within the normal range over 48-72 hours.
Subarachnoid Hemorrhage
Preferred treatments: Esmolol, Labetalol, Nicardipine
Systolic BP (SBP) should be maintained at <160 mmHg until the aneurysm is treated or cerebral vasospasm occurs.
Malignant Hypertension with or without Acute Renal Failure
Preferred treatments: Labetalol, Nicardipine
Nitroprusside or Urapidil can be given as an alternative agent. MAP should be reduced by 20-25%.
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. Alpha-blockers are the preferred agents. Avoid selective beta-blockers, which can worsen hypertension.
Preferred treatments for pheochromocytoma: Clevidipine, Labetalol with Nitroprusside, Nicardipine, Phentolamine, Urapidil
SBP should be reduced to <140 mmHg within the first hour of therapy.
Preferred treatments for sympathetic crisis related to use of sympathomimetic drugs: Benzodiazepines, Clonidine, Diltiazem, Labetalol with Nitroprusside, Nicardipine in combination with Benzodiazepine, Phentolamine, Verapamil
Rapidly lower blood pressure until symptoms resolves.
Severe Preeclampsia or Eclampsia
Hypertensive Crisis_Management 5
Preferred treatments: Hydralazine, Labetalol, Nicardipine, Nifedipine
SBP should be reduced to <140 mmHg within the first hour of therapy. SBP >160 mmHg has been associated with cerebrovascular accidents. Magnesium sulfate should be given to prevent seizures. Avoid Nitroprusside, ACE inhibitors, ARBs, renin inhibitors, and Esmolol.
Please see Hypertension
in Pregnancy disease management chart for further information.
Acute Postoperative Hypertension
Preferred treatments: Clevidipine, Esmolol, Labetalol, Nicardipine, Urapidil
Treatment is indicated in cardiac surgery patients with a BP >140/90 mmHg or a MAP of at least 105 mmHg.
Acute Severe Hypertension
The term “hypertensive urgency” has led to overly aggressive management of many patients.
Reduce BP to ≤160/100 mmHg over hours to days. MAP should not be lowered by >25-30% within the first several hours. Reduction of BP in these patients may be achieved with short-acting oral medications and without intensive monitoring. Consider the addition of a diuretic in patients with high sodium intake resulting in worsening hypertension. Asymptomatic patients with acute severe hypertension may be managed with standing medications and close frequent monitoring while avoiding the use of as-needed drugs. No consensus exists stating that initiating treatment in the ED is cost-effective and improves long-term patient care.
Preferred Medications for Acute Severe Hypertension
Please see Hypertension disease
management chart for full dosage guidelines of the following oral agents:
Captopril
Hypertensive Crisis_Management 6
Captopril is considered a first-line agent. The onset of action is within 30-60 minutes. Co-administration of a loop diuretic1 enhances the effect of this drug. Avoid in patients with high-grade bilateral renal artery stenosis or volume overload.
1Please see Hypertension disease management chart for dosage
guidelines of diuretics.
Amlodipine
Amlodipine has an onset of action within 30-50 minutes.
Clonidine
Clonidine has an onset of action within 30-60 minutes. Avoid in patients requiring mental status monitoring; this is not intended for long-term use.
Labetalol
Labetalol has an onset of action within 20-120 minutes. Avoid in patients with asthma, as this may worsen bronchospasm. Use with caution in patients with symptomatic bradycardia, congestive HF, and heart block.
Nifedipine (Extended-release)
Nifedipine has an onset of action within 30 minutes. Avoid the use of short-acting oral or sublingual Nifedipine due to the risk of stroke, AMI, and severe hypotension.
Prazosin
Hypertensive Crisis_Management 7
Prazosin has an onset of action within 2-4 hours. This may cause postural hypotension and syncope with the first dose.