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Hypertensive Emergency

A summary of the hypertensive emergency treatment guidelines from:

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Full Text     PubMed

Acute Aortic Dissection
  • Preferred drugs: esmolol, labetalol
  • Reduce SBP to < 120 mm HG within 20 min.
  • Beta blockers before vasodilators (nicardipine, nitroprusside) if needed, to prevent reflex tachycardia or inotropic effects
Acute Pulmonary Edema
  • Preferred drugs: clevidipine, nitroglycerin, nitroprusside
  • Beta blockers contraindicated
Acute Coronary Syndromes
  • Preferred drugs: esmolol, nitroglycerin
  • Alternates: labetalol, nicardipine
  • Ask about PDE-5 inhibitor use which can cause severe hypotension when combined with nitrates
    • Viagra (sildenafil)
    • Cialis (tadalafil)
    • Levitra (vardenafil)
  • Beta blocker contraindications include:
    • Mod to severe LV failure with pulmonary edema
    • Bradycardia <60 bpm
    • Hypotension, SBP <100 mm Hg
    • Poor peripheral perfusion
    • 2nd or 3rd degree heart block
    • Reactive airway disease
Acute Renal Failure
  • Preferred drugs: clevidipine, fenoldopam, nicardipine
Eclampsia or Pre-eclampsia
  • Preferred drugs: hydralazine, labetalol, nicardipine
  • Reduce SBP rapidly
  • Contraindicated medications include:
    • ACE-i
    • ARBs
    • Renin inhibitors
    • Nitroprusside
Perioperative Hypertension
  • Preferred drug: clevidipine, esmolol, nicardipine, nitroglycerin
  • Defined as BP > 160/90 mm Hg or SBP > 20% of preoperative value for > 15 min.
  • Intraoperastive hypertension most frequently due to anesthesia induction and airway manipulation
Acute Sympathetic Discharge or Catecholamine Crisis 
  • Preferred drug: celvidipine, nicardipine, phentolamine
  • Seen with pheochromocytoma, post-carotid endarterectomy state
  • Reduce SBP rapidly
Acute Ischemic Stroke
  • If eligible for TPA or endovascular intervention, lower BP to < 185/110 mm Hg before thrombolytic therapy, and maintain <180/105 mm Hg for first 24 hours.
  • Not eligible for TPA or endovascular intervention and BP > 220/120 mm Hg
    • Reasonable to lower BP 15% in first 24 hours
    • Benefit of aggressive BP management in first 48-72 hours is uncertain
  • Not eligible for TPA or endovascular intervention and BP < 220/120 mm Hg, starting or reinitiating anti-hypertensive treatment within 48-72 hours does not reduce death or disability
Acute ICH (spontaneous)
  • SBP > 220 mm Hg, reasonable to use IV infusion and close BP monitoring to lower SBP.
  • SBP 150-220 mm Hg, lowering SBP to < 140 mm Hg is not beneficial and may be harmful.
  • Information about the safety and effectiveness of early intensive BP-lowering treatment is least well established for patients with markedly elevated BP (sustained SBP >220 mm Hg) on presentation, patients with large and severe ICH, or patients requiring surgical decompression. However, given the consistent nature of the data linking high BP with poor clinical outcomes and some suggestive data for treatment in patients with modestly high initial SBP levels, early lowering of SBP in ICH patients with markedly high SBP levels (>220 mm Hg) might be sensible. A secondary endpoint in 1 RCT and an overview of data from 4 RCTs indicate that intensive BP reduction, versus BP-lowering guideline treatment, is associated with greater functional recovery at 3 months.”
  • “RCT data have suggested that immediate BP lowering (to <140/90 mm Hg) within 6 hours of an acute ICH was feasible and safe, may be linked to greater attenuation of absolute hematoma growth at 24 hours, and might be associated with modestly better functional recovery in survivors. However, a recent RCT that examined immediate BP lowering within 4.5 hours of an acute ICH found that treatment to achieve a target SBP of 110 to 139 mm Hg did not lead to a lower rate of death or disability than standard reduction to a target of 140 to 179 mm Hg. Moreover, there were significantly more renal adverse events within 7 days after randomization in the intensive-treatment group than in the standard-treatment group. Put together, neither of the 2 key trials evaluating the effect of lowering SBP in the acute period after spontaneous ICH met their primary outcomes of reducing death and severe disability at 3 months.”


Reproduced from Table 19 “Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies”

ClassDrugDose RangeComments
Calcium Channel BlockersNicardipine5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h.Contraindicated in advanced aortic stenosis; no dose adjustment needed for elderly.
Clevidipine1–2 mg/h, doubling every 90 sec until BP approaches target, then increasing by less than double every 5–10 min; maximum dose 32 mg/h; maximum duration 72 h.Contraindicated in patients with soybean, soy product, egg, and egg product allergy and in patients with defective lipid metabolism (e.g., pathological hyperlipidemia, lipoid nephrosis or acute pancreatitis). Use low-end dose range for elderly patients.
Nitric-oxide VasodilatorsSodium nitroprusside0.3–0.5 mcg/kg/min; increase in increments of 0.5 mcg/kg/min to achieve BP target; maximum dose 10 mcg/kg/min; duration of treatment as short as possible. For infusion rates ≥4–10 mcg/kg/min or duration >30 min, thiosulfate can be coadministered to prevent cyanide toxicity.Intra-arterial BP monitoring recommended to prevent “overshoot.” Lower dosing adjustment required for elderly. Tachyphylaxis common with extended use.
Cyanide toxicity with prolonged use can result in irreversible neurological changes and cardiac arrest.
Nitroglycerin 5 mcg/min; increase in increments of 5 mcg/min every 3–5 min to a maximum of 20 mcg/min (then begin increasing by 10 mcg/min every 3-5 min until adequate response, max 200 mcg/min).Use only in patients with acute coronary syndrome and/or acute pulmonary edema. Do not use in volume-depleted patients.
Direct VasodilatorsHydralazineInitial 10 mg via slow IV infusion (maximum initial dose 20 mg); repeat every 4–6 h as needed.BP begins to decrease within 10–30 min, and the fall lasts 2–4 h. Unpredictability of response and prolonged duration of action do not make hydralazine a desirable first-line agent for acute treatment in most patients.
Beta Blockers - B1 selectiveEsmololLoading dose 500–1000 mcg/kg/min over 1 min followed by a 50-mcg/kg/min infusion. For additional dosing, the bolus dose is repeated and the infusion increased in 50-mcg/kg/min increments as needed to a maximum of 200 mcg/kg/min.Contraindicated in patients with concurrent beta-blocker therapy, bradycardia, or decompensated HF.
Monitor for bradycardia.
May worsen HF.
Higher doses may block beta2 receptors and impact lung function in reactive airway disease.
Alpha and Beta BlockersLabetalol0.3–1.0-mg/kg dose (maximum 20 mg) slow IV injection every 10 min or 0.4–1.0-mg/kg/h IV infusion up to 3 mg/kg/h. Adjust rate up to total cumulative dose of 300 mg. This dose can be repeated every 4–6 h.Contraindicated in reactive airways disease or chronic obstructive pulmonary disease. Especially useful in hyperadrenergic syndromes. May worsen HF and should not be given in patients with second- or third-degree heart block or bradycardia.
Non-selective Alpha BlockersPhentolamineIV bolus dose 5 mg. Additional bolus doses every 10 min as needed to lower BP to target.Used in hypertensive emergencies induced by catecholamine excess (pheochromocytoma, interactions between monamine oxidase inhibitors and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal).
Dopamine1-receptor selective agonistFenoldopam0.1–0.3 mcg/kg/min; may be increased in increments of 0.05–0.1 mcg/kg/min every 15 min until target BP is reached. Maximum infusion rate 1.6 mcg/kg/min.Contraindicated in patients at risk of increased intraocular pressure (glaucoma) or intracranial pressure and those with sulfite allergy.
ACE inhibitorEnalaprilat1.25 mg over a 5-min period. Doses can be increased up to 5 mg every 6 h as needed to achieve BP target.Contraindicated in pregnancy and should not be used in acute MI or bilateral renal artery stenosis.
Mainly useful in hypertensive emergencies associated with high plasma renin activity.
Dose not easily adjusted.
Relatively slow onset of action (15 min) and unpredictability of BP response.


ACC/AHA Spontaneous ICH Algorithm

ACC/AHA Ischemic Stroke Algorithm

ACC/AHA Hypertensive Emergency Algorithm 

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