Hypertensive Urgency Emergency

University of Maryland Medical Center Hypertensive Urgency/Emergency Guidelines for Use Hypertensive Urgency DEFINITION Upper levels of Stage 3 hypertension (SBP ≥ 180 or DBP ≥ 110 in the presence of one or more of the following: ♦ Hypertension with optic disc edema ♦ Severe perioperative hypertension ♦ Progressive target organ damage GOAL ♦ ♦ ♦

Reduce DBP < 100 – 110 mm Hg within several hours. Rate of lowering should be individualized. Correct to normal over 2-3 days Improve progression, reverse symptoms, and/or arrest progression of end organ damage.

TREATMENT ♦ Oral agents with relatively fast onset of action: Dose Onset Duration Side Effects Caution Note

Clonidine 0.2 mg PO initial, 0.1 mg Q1H Max = 0.8 mg 30 minutes-2 hrs 6-8 hrs Sedation, dry mouth, dizziness Altered mental status, severe carotid artery stenosis

Captopril 6.25–50 mg PO* 15 minutes 4-6 hr Rash, pruritus, proteinuria, loss of taste, hypotension RAS, hyperkalemia, dehydration, renal failure, pregnancy *SL administration has been reported and may be used.

RAS = Renal Artery Stenosis, SL = sublingual, CHF = Congestive Heart Failure

Labetalol 100–300 mg po q23hrs or 200-400 mg PO Q2-3H 30 minutes-2 hrs 4 hrs Orthostatic hypotension, nausea, vomiting CHF, asthma, bradycardia, heart block Response rates not always predictable

SL OR ORAL (FAST-ACTING) NIFEDIPINE SHOULD NEVER BE USED ⇒ Serious adverse events  Renal, cardiac, and cerebral ischemia 1. Uncontrolled fall in BP 2. Peripheral vasodilatation produces steal phenomenon 3. Reflex sympathetic nervous system and catecholamine release 4. May increase mortality ♦ Furosemide     

May be appropriate especially in face of volume overload, pulmonary edema Dose: 10 – 200 mg PO/IV Onset: ~ 30 minutes Duration: 4 – 6 hours Side effects: orthostatic hypotension, dizziness, hypokalemia

NOTE Elevated blood pressure alone, in the absence of symptoms or new or progressive target organ damage rarely requires emergency therapy and may be secondary to non-compliance. Patients may be re-started on their antihypertensive medications and followed closely for the next week.

Hypertensive Emergency DEFINITION Severe elevation of blood pressure (e.g. DBP ≥ 120) in the presence of one or more of the following ♦ Cardiac - acute aortic dissection, acute pulmonary edema, unstable angina, acute myocardial infarction, left ventricular failure ♦ CNS - intracranial hemorrhage, thrombotic cerebrovascular accident, subarachnoid hemorrhage, encephalopathy ♦ Renal – renal failure May also include: ♦ Eclampsia ♦ Pheochromocytoma crises ♦ Drug induced hypertensive crises  MAOI – tyramine interactions  Overdose with phencyclidine, cocaine, LSD

GOAL Limit or prevent target organ damage, not immediate reduction to normal blood pressure ♦ Reduce mean arterial blood pressure by 25% initially within minutes to 2 hours, then toward 160/100 mm Hg within 2-6 hours. Avoid excessive falls in pressure that may precipitate renal, coronary, or cerebral ischemia ♦ Goal DBP approximately 100 – 110 mm Hg. May need lower goals for patients with aortic dissection. ♦ Correct to normal blood pressure within 2-3 days ♦

TREATMENT ♦ Initially IV medications ♦ SL or oral (fast-acting) nifedipine should never be used ⇒ Serious adverse events  Renal, cardiac, and cerebral ischemia 1. Uncontrolled fall in BP 2. Peripheral vasodilatation produces steal phenomenon 3. Reflex sympathetic nervous system and cathecolamine release 4. May increase mortality ♦ Patients should be started on oral medications as soon as they are stabilized. Parenteral antihypertensives should be gradually tapered. Comorbidities with Severe Hypertension Heart Failure Renal Insufficiency Acute Coronary Ischemia

Preferred Treatment

Nitroprusside Nitroprusside Fenoldopam* Nitroglycerin, Labetolol, Nitroprusside Cerebrovascular Accident Labetolol Eclampsia Hydralazine, Labetolol Aortic Dissection Nitroprusside + beta blocker * See restrictions for Fenoldopam

Avoid Labetolol Hydralazine Nitroprusside, Nitroglycerin Nitroprusside Hydralazine, ACE inhibitors

Drug

Dose/ Route

Onset of Duration Side Action of Effects Action Nitroprusside 0.25 Seconds 3-5min Cyanide and mcg/kg/min thiocyanate -8 toxicity, mcg/kg/min hypotension IV

Fenoldopam 0.1-0.3 < 5 min mcg/kg/min ↑ dosage by 0.05-0.1 mcg/kg/min q15 min

Labetolol

2 mg/min ≤ 5 min IV or 20-80 mg Q10 min up to Max dose 300 mg

30 min

3-6 hr

Headache, flushing, dizziness, tachycardia

Caution Pregnancy, increased intracranial pressure, renal failure

Monitoring

Continuous intra-arterial BP Cyanide toxicity (MS change, coma metabolic status, lactic acidosis, seizures, smell of almonds) Glaucoma, BP, Serum intraocular electrolytes, hypertension (low K+)

Note Considered first line ↑ dose slowly by 0.25 ug/kg/min; Max 10 mcg/kg/min; If BP control not achieved within 10 min of max rate, D/C gtt Cyanide toxicity usually seen at infusion > 3 mcg/kg/min

Restricted for patients: With pre-existing renal insufficiency (SCr> 2) With hepatic dysfunction (INR>1.5, Bil >3, transaminase > 3X normal) requiring nitroprusside infusion > 2 mcg/kg/min Requiring nitroprusside infusion > 10 mcg/kg/min or > 4 mcg/kg/min > 10 hours, refractory to other treatment Orthostatic Asthma, Orthostasis, BP Use in patients with hypotension, bradycardia, underlying CAD, acute MI, abdominal heart block, angina, or following vascular pain, decompensa surgical procedures. dizziness, ted CHF May be useful in patients nausea, with cerebrovascular disease. vomiting, May use in patients with diarrhea eclampsia

Drug Hydralazine

Dose/ Route 10-20 mg IV 10-50 mg IM

Nitroglycerin 5-100 mcg/min IV infusion

Esmolol

250-500 µ g/kg/min for 1 min then 50 – 100 µ g/kg/min for 4 min; may repeat sequence

Onset of Duration Side Action of Effects Action 10-30 2-6 Angina, min (IV) hours tachycardia, 20-40 headache min (IM)

Caution

Monitoring

Coronary ischemia, angina, MI, aortic dissection 2-5 min 5-10 min Methemoglo Pericardial after D/C binemia, tamponade, infusion headache, pericarditis, tachycardia, increased nausea, intracranial vomiting, pressure flushing, tolerance with prolonged use 1 – 2 min 10–20 Thrombophl Asthma, BP, heart rate min ebitis, bradycardia, hypotension, heart block, nausea decompensa ted CHF

Note Use in patients with eclampsia Rarely used to treat crises because of unpredictable response. Avoid use. Preferred in patients with coronary ischemia, unstable angina, acute MI

May be used for perioperative HTN and aortic dissection Use for ≤ 24 hours