Management of hypertensive urgencies & emergencies

Emergencies: BP> 180/120 – impending/ progressive target organ damage - Immediate reductions required. Urgencies: severe elevations in BP without progressive target organ damage - Severe headache, shortness of breath, epistaxis, severe anxiety

Emergencies:- decrease mean BP by 25%(within minutes to one hour) - If stable  to 160/ mmHg – next 2 – 6 hrs. - Excessive fall!!! -If stable – normal BP – 24 – 48 hrs EXCEPTIONS: Patients with ischemic stroke - Aortic dissection (↓SBP to <100 mmHg) - Patients in whom BP is lowered to enable use of thrombolytic agents

Oral agents: captopril, labetalol, clonidine Complications of aggressive management!

Treatment of acute severe hypertension in preeclampsia Hydralazine ■ 5 mg iv bolus, then 10 mg every 20–30 minutes to a maximum of 25 mg, repeat in several hours as necessary Labetalol (second-line) ■ 20 mg iv bolus, then 40 mg 10 minutes later, 80 mg every 10 minutes for two additional doses to a maximum of 220 mg Sodium nitroprusside (rarely, when others fail) ■ 0.25 μg/kg/min to a maximum of 5 μg/kg/min ■ Fetal cyanide poisoning may occur if used for more than 4 hours

Treatment of acute severe hypertension in preeclampsia Nifedipine (controversial) ■ 10 mg po, repeat every 20 minutes to a maximum of 30 mg ■ Caution when using nifedipine with magnesium sulfate, can see precipitous blood pressure drop ■ Short-acting nifedipine is not approved by the Food and Drug Administration for managing hypertension

Drug Sodium nitroprusside Dose 0.25–10 μg/kg/min as IV infusion Onset of Action Immediate Duration of Action 1–2 min Adverse Effects: Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication Special Indications: Most hypertensive emergencies; caution with high intracranial pressure or azotemia

Drug: Nicardipine hydrochloride Dose: 5–15 mg/h IV Onset of Action: 5–10 min Duration of Action: min, may exceed 4 hrs Adverse Effects: Tachycardia, headache, flushing, local phlebitis Special Indications: Most hypertensive emergencies except acute heart failure; caution with coronary ischemia

Drug:Fenoldopam mesylate Dose: 0.1–0.3 μg/kg per min IV infusion Onset of Action: <5 min Duration of Action: 30 min Adverse Effects: Tachycardia, headache, nausea, flushing Special Indications: Most hypertensive emergencies; caution with glaucoma

Drug: Nitroglycerin Dose: 5–100 μg/min as IV infusion Onset of Action: 2–5 min Duration of Action: 5–10 min Adverse Effects: Headache, vomiting, methemoglobinemia, tolerance with prolonged use Special Indications: Coronary ischemia

Drug: Enalaprilat Dose: 1.25–5 mg every 6 hrs IV Onset of Action: 15–30 min Duration of Action: 6–12 hrs Adverse Effects: Precipitous fall in pressure in high- renin states; variable response Special Indications: Acute left ventricular failure; avoid in acute myocardial infarction

Drug:Hydralazine hydrochloride Dose: 10–20 mg IV 10–40 mg IM Onset of Action: 10–20 min IV 20–30 min IM Duration of Action:1–4 hrs IV 4–6 hrs IM Adverse Effects: Tachycardia, flushing, headache, vomiting,aggravation of angina Special Indications: Eclampsia

Drug: Labetalol hydrochloride Dose: 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion Onset of Action: 5–10 min Duration of Action: 3–6 hrs Adverse Effects: Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension Special Indications: Most hypertensive emergencies except acute heart failure

Drug: Esmolol hydrochloride Dose: 250–500 μg/kg/min IV bolus, then 50– 100 μg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to300 μg/min Onset of Action: 1–2 min Duration of Action: 10–30 min Adverse Effects: Hypotension, nausea, asthma, first degree heart block, heart failure Special Indications: Aortic dissection, perioperative

Drug: Phentolamine Dose: 5–15 mg IV bolus Onset of Action: 1–2 min Duration of Action: 10–30 min Adverse Effects: Tachycardia, flushing, headache Special Indications: Catecholamine excess