Hypertensive Crisis
HTN emergency HTN Urgency
BP > 180/120 WITH new/worsening target organ damage BP > 180/120 without new/worsening target organ damage
Treatment strategy: admit to ICU and use parenteral administration (not oral) “severe BP elevation” in stable patients without acute/impending change in target
Treatment goal: minimize target organ damage and provide appropriate antihypertensive drugs organ damage or dysfunction
If patients have a compelling condition In absence of compelling condition Common causes: withdrawal of therapy, noncompliance
Severe preeclampsia/eclampsia, or pheochromocytoma crisis 1st hour
Reduce SBP < 140 during 1st hour Reduce SBP by 25% Treatment strategy: reinstitution or intensification of antihypertensive therapy,
Aortic dissection Next 2 – 6 hours treatment of anxiety (no indication for ED referral or hospitalization)
Reduce SBP < 120 during 1st hour Reduce to 160/110 (if stable)
In next 24 – 48 hours
“cautiously to normal”
Preeclampsia/eclampsia Pheochromocytoma Crisis Acute Aortic dissection
SBP 140 and/or DBP 90 + proteinuria Rapidly reduce SBP to < 140 during 1st hour Tearing of the inner layer of aorta New/worsening target organ damage
(> 300mg/24H) after 20 weeks gestation Examples include Presentation Hypertensive encephalopathy
Eclampsia = preeclampsia + seizures cocaine/amphetamine overdose, MAO- Severe chest pain or back pain, SOB ICH
Risk Factors i/clonidine withdrawal, pheochromocytoma, Risk factors Acute ischemic stroke
HTN, CKD, type I/II and gestational diabetes, pre- hypoaldosteronism Uncontrolled HTN, atherosclerosis Acute MI
pregnancy obesity Drugs of choice Treatment goal Acute LV failure + pulmonary edema
Treatment goal Clevidipine, nicardipine, phentolamine Rapidly reduce SBP to < 120 (within 20 min but can be up to 1 Unstable angina pectoris
Rapidly reduce SBP < 140 during 1st hour hour) Dissected aortic aneurism
Drugs of choice Drugs of choice Acute renal failure
Labetalol, hydralazine, nicardipine Beta blockers first (esmolol, labetalol) Eclampsia
ACEI, ARBs, renin inhibitors, potassium sparing diuretics, then vasodilator if needed (nicardipine, nitroprusside) to prevent
or mineralocorticoid receptor blockers reflex tachycardia/inotropic effect
Nicardipine Clevidipine Sodium nitroprusside Nitroglycerin Hydralazine Fenoldopam Esmolol Labetalol Phentolamine enalaprilat
DHP CCB DHP CCB NO dependent vasodilator NO-dependent vasodilator Direct vasodilator Dopamine agonist Adrenergic blocker – beta Adrenergic blocker – a1 Adrenergic blocker ACE-i
Titratable IV Titratable IV selective antagonist selective and non-selective nonselective a blocker
beta receptor antagonist
Initial dose Initial dose Initial dose Initial dose Initial dose Initial dose Loading dose Initial dose Initial dose Initial dose
5mg/hr increase every 5 1 – 2 mg/hr, double every 90 sec 0.3-0.5 mcg/kg/min increase 5mcg/min, increase by 10 mg vial slow IV fusion can repeat 0.1-0.3 mcg/kg/min 500-1000mcg/kg/min over 1 0.3-1 mg/kg IV bolus over 2 5mg IV bolus, may give 1.25mg IV over 5 min
min by 2.5mg/hr until until target SBP reached, then by 5mcg/min Q 3-5 min until 5mcg/min Q 3-5 min until every 4 – 6 hours as needed increase by 0.05-0.1 min, then 50mcg/kg/min min, dose escalation every additional boluses every Dose escalation by
target SBP reached once in increase by less than double target SBP reached target SBP reached Max 20 mg mcg/kg/min Q 15 min infusion or increased by 10 min until SBP reached 10 min until target SBP 5mg Q 6 hours until
target reduce to 3mg/hr every 5 – 10 min Max 20mcg/min Max 20mcg/min as needed 50mcg/kg/min increments Max 300 mg reached target SBP reached
max 15mg/hr Max 32mg/hr max duration 72H Max 1.6mcg/kg/min Max 200mcg/kg/min
Onset Onset Onset Onset Onset Onset Onset Onset Onset Onset
5-15 min 2 -4 min 1 -2 min 1 – 5 min (IV) 5 – 15 min 10 min 5 min 2 -5 min immediate 0.5 min – 4 hours
Clinical offset 30 min DOA up to 4 hours
Hepatic metabolism Metabolism Metabolism Metabolism Metabolism Metabolism Metabolism Metabolism Metabolism Metabolism
Rapid and extensive Rapid hydrolysis to inactive Extensive hepatic Hepatic metabolism to active Significant hepatic metabolism Red blood cells Hepatically to inactive Hepatic Renally excreted
metabolites in blood metabolites glucuronide conjugate without metabolism
1,2-dinitroglycerin
1,3-dinotroglycerin
ADRs ADRs ADRs ADRs ADRs ADRs ADRs ADRs ADRs ADRs
Reflex tachycardia Atrial fibrillation Tachyphylaxis – extended Flushing Reflex tachycardia Reflex tachycardia Bradycardia Bradycardia Hyperkalemia
Flushing Insomnia use Headache Flushing Cerebral ischemia Headache Angioedema
Headache Nausea Cyanide toxicity Erythema Headache Flushing Post-injection pain Caution in renal
N/V Fatigue may intracranial pressure Hypokalemia Mouth pain insufficiency
Contraindications Contraindications Contraindications Contraindications Contraindications Contraindications Contraindications Contraindications Contraindications Contraindications
Advanced aortic stenosis Soybean/egg allergy Renal failure Do NOT use in volume- intraocular pressure Already on beta blocker, Reactive airway disease Current/past MI Pregnancy
Caution in acute heart Defected lipid metabolism Hepatic failure depleted patients (glaucoma) or bradycardia COPD CAD Use in acute MI
failure Caution in hypertriglyceridemia intracranial pressure Angina Bilat renal artery
Angina/MI Sulfite allergy Coronary insufficiency stenosis
Protect from light even Protect from light until Unpredictable response and varied Caution/not recommend Caution/not recommend Use in HTN crisis Useful in HTN
during infusion administered duration of action, not preferred 1st 2nd or 3rd degree heart block 2nd or 3rd degree heart block secondary to emergencies
Cyanide toxicity – general Use only in ACS, acute line agent ADHF Bradycardia catecholamine excess – secondary to high
weakness, confusion, pulmonary edema Systemic lupus erythematosus-like ADHF pheochromocytoma, DDI plasma renin activity
excessive sleeping, coma, symptoms especially with higher doses with MAO-i and other
SOB, red-pink skin – joint pain, swelling, fatigue, fever drugs/food, cocaine
For infusion rate >4- with no other cause, weight loss, hair toxicity, amphetamine
10mcg/kg/min or duration loss, mouth sores, personality changes, overdose, clonidine
>30 min use thiosulfate patchy skin withdrawal
concomitantly to prevent
cyanide toxicity
