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Treatment of Hypertensive Emergencies
HYPERTENSIVE EMERGENCY
Hypertension associated with acute organ dysfunction
- Organ Dysfunction
- MI, Aortic Dissection, LV Failure with Pulmonary Edema, Encephalopathy, Hemorrhagic Stroke, Microangiopathic Hemolytic Anemia, Pregnancy, Acute Post-Operative
- Goal BP reduction of MAP 20% in the first hour
- Gradual normalization over the next 24-48h
- Unless unclipped aneurysmal bleed or aortic dissection (decrease faster as below)
| Clinical Setting | Goal Blood Pressure | Timing | Preferred Agents | Comment |
| Aortic Dissection | Systolic BP <120 or normalizing BP | <20 min | Esmolol followed by nicardipine or nitroprusside or labetalol | Adequate B-blockade should precede initiation of vasodilators |
| Acute ischemic cerebrovascular accident | Systolic BP <220 | Within 1 h | Labetalol, nicardipine | Goal systolic BP <185 in patients eligible for thrombolytic therapy |
| Acute hemorrhagic stroke | Systolic BP <140 | Within 1 h | Labetalol, nicardipine | Reduces hematoma growth |
| Hypertensive encephalopathy | MAP lower by 20% to 25% | Within 1 h | Labetalol, nicardipine, or nitroprusside | Avoid sodium nitroprusside |
| Pregnancy | Diastolic BP <110 | Within 1 h if preeclampsia | IV hydralazine or labetalol, nicardipine | Addition of magnesium for preeclampsia (ultimate treatment is delivery |
| Postoperative hypertension | Systolic BP <180 | Within 1 h | Nicardipine or labetalol | Treat reversible factors first |
HYPERTENSIVE URGENCY
Elevated blood pressure without end-organ damage
- Oral medication to bring down BP over 24-48 hours
- Start with uptitrating home regimen (or giving missed dose)