Hypertension

Hypertensive Emergency

Must Rule out Known Causes of Hypertensive Emergency that have specific treatments

• Pre-eclampsia
• Aortic Dissection
• Sympathetic Crashing Acute Pulmonary Edema (SCAPE)/Flash Pulmonary Edema
• Type 1 MI
• Stroke
• Scleroderma Renal Crisis
• Sympathomimetic/Cocaine intoxication
• Hyperthyroidism
• Uncontrolled Pain
• Urinary Obstruction

Evaluation

• Labs
  • CBC, CMP, PT/INR, PTT
  • Troponin + EKG
  • Urinalysis
  • +/- UTox
  • b-hCG

Criteria

• End Organ Damage
  • AKI
  • Type II MI
  • Encephalopathy
  • Pulmonary Edema
  • (Not Headache)
• Severe Hypertension: MAP > 135mmHg, or well above patient’s baseline

Treatment Goal

• <25% in first hour
• 160/100 (or MAP 125) within 2-6 hours
• Normal in 24-48 hours

Treatment

Medication	Load	Initial Rate	Increase Rate	Maximum
Nicardipine		5mg/h	+2.5mg/h q5m	15mg/h
Sodium Nitroprusside		0.3-0.5 mcg/kg/min	0.5/mcg/kg/min q5m	10mcg/kg/min
Labetalol	0.3-1mg/kg (MAX 20mg)	N/A	BOLUS 20-80 mg q10m until target reached	300mg cumulative
Esmolol	500mcg/kg in 1m	50-150 mcg/kg/min		200 mcg/kg/min

Choice of Agents

Nicardipine: Good for most cases, Avoid in Cirrhosis, can accumulate and cause hypotension (Reduce dose to 3-5mg/h once target reached)

Nitroglycerine: Preferred in SCAPE or MI; Low doses: Venodilation; High doses: Veno- and Arterial dilation

Nitroprusside: Can increase ICP, Cyanide Toxicity/Lactic Acidosis, Wide BP swings, Coronary steal

Oral Antihypertensives

Transition to Orals once stabilized

• Nifedipine XR: Dosed qD (Avoid immediate release), Onset 2-4hours, lasts 24h

  • Start 30-60mg

• Labetalol: Can crosstitrate, downtitrating labetalol IV PRNs

  • Start 200mg q12h, redose x1 in 4 hours; Max 1000mg q12h

• (Avoid Amlodipine - takes forever to work)

• (Avoid Metoprolol - doesn’t affect BP)

• (Avoid Carvedilol - takes >24h to reach steady state)

Hypertensive Urgency

Treatment

• Nicardipine 20-40mg PO q8-12h
• Captopril 25-50mg PO q8-12h
• Labetalol 200mg once, then 200-400mg q6-12h