Focused Update on Pharmacologic Management of Hypertensive Emergencies
Purpose of Review
Hypertensive emergency is defined as a systolic blood pressure > 180 mmHg or a diastolic blood pressure > 120 mmHg with evidence of new or progressive end-organ damage. The purpose of this paper is to review advances in the treatment of hypertensive emergencies within the last 5 years.
New literature and recommendations for managing hypertensive emergencies in the setting of pregnancy, stroke, and heart failure have been published.
Oral nifedipine is now considered an alternative first-line therapy, along with intravenous hydralazine and labetalol for women presenting with pre-eclampsia. Clevidipine is now endorsed by guidelines as a first-line treatment option for blood pressure reduction in acute ischemic stroke and may be considered for use in intracranial hemorrhage. Treatment of hypertensive heart failure remains challenging; clevidipine and enalaprilat can be considered for use in this population although data supporting their use remains limited.
KeywordsHypertensive emergency Hypertensive crisis, intravenous antihypertensive medications
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. 2010;121(13):e266-e369.Google Scholar
- 2.Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex : 1979). 2017.Google Scholar
- 6.Gonzalez Pacheco H, Morales Victorino N, Nunez Urquiza JP, Altamirano Castillo A, Juarez Herrera U, Arias Mendoza A, et al. Patients with hypertensive crises who are admitted to a coronary care unit: clinical characteristics and outcomes. J Clin Hypertens (Greenwich). 2013;15(3):210–4.CrossRefGoogle Scholar
- 11.American College of O, Gynecologists, Task Force on Hypertension in P. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Task_Force_and_Work_Group-Reports/Hypertension-in-Pregnancy Accessed 10 Jan 2018.
- 16.• Shekhar S, Sharma C, Thakur S, Verma S. Oral nifedipine or intravenous labetalol for hypertensive emergency in pregnancy: a randomized controlled trial. Obstet Gynecol. 2013;122(5):1057–63. A double-blind, randomized, controlled trial of pregnant women with severe pre-eclampsia were given either oral immediate-release nifedipine or IV labetalol. Time to target blood pressure was not statistically significant between the two arms and there were no differences in serious side effects. CrossRefGoogle Scholar
- 18.• Sharma C, Soni A, Gupta A, Verma A, Verma S. Hydralazine vs nifedipine for acute hypertensive emergency in pregnancy: a randomized controlled trial. Am J Obstet Gynecol. 2017;217(6):687.e1–6. A double-blinded, randomized, controlled trial of pregnant women with hypertensive emergency received either IV hydralazine or oral immediate release nifedipine. The time to target blood pressure was 40 min in each arm. CrossRefGoogle Scholar
- 19.• Cornette J, Buijs EA, Duvekot JJ, Herzog E, Roos-Hesselink JW, Rizopoulos D, et al. Hemodynamic effects of intravenous nicardipine in severely pre-eclamptic women with a hypertensive crisis. Ultrasound Obstet Gynecol. 2016;47(1):89–95. A ten-patient study of nicardipine in pregnant women with pre-eclampsia evaluated both maternal hemodynamic changes and uteroplacental and fetal perfusion. CrossRefPubMedCentralPubMedGoogle Scholar
- 23.Bijvank SW, Visser W, Duvekot JJ, Steegers EA, Edens MA, Roofthooft DW, et al. Ketanserin versus dihydralazine for the treatment of severe hypertension in early-onset preeclampsia: a double blind randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015;189:106–11.CrossRefPubMedCentralPubMedGoogle Scholar
- 25.Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke - April 18, 2018. The revised, online version of the guideline is available at: http://stroke.ahajournals.org/content/49/3/e46.
- 26.• Allison TA, Bowman S, Gulbis B, Hartman H, Schepcoff S, Lee K. Comparison of clevidipine and nicardipine for acute blood pressure reduction in patients with stroke. J Intensive Care Med. 2017:885066617724340. A retrospective evaluation of patients receiving either clevidipine or nicardipine for acute ischemic or hemorrhagic stroke showed no difference in time to target blood pressure. Google Scholar
- 27.•• Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65. An international, multicenter, open-label, randomized trial evaluated intense blood pressure control (SBP < 140 mmHg) versus guideline-recommended treatment (SBP < 180 mmHg) and found no difference in the primary endpoint of death or severe disability. CrossRefPubMedGoogle Scholar
- 28.•• Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033–43. A multicenter, open-label, randomized trial evaluated intensive blood pressure control (SBP 110–139 mm Hg) vs standard medical care (SBP < 180 mmHg) and found no difference in the rate of death or disability between the two groups. CrossRefPubMedCentralPubMedGoogle Scholar
- 29.Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032–60.CrossRefPubMedGoogle Scholar
- 31.Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–239.CrossRefPubMedCentralPubMedGoogle Scholar
- 32.•• Viau DM, Sala-Mercado JA, Spranger MD, O'Leary DS, Levy PD. The pathophysiology of hypertensive acute heart failure. Heart. 2015;101(23):1861–7. A review of the pathophysiology of acute heart failure due to hypertensive emergency, including graphs and images of hemodynamic changes that occur. CrossRefPubMedCentralPubMedGoogle Scholar
- 33.• Ayaz SI, Sharkey CM, Kwiatkowski GM, Wilson SS, John RS, Tolomello R, et al. Intravenous enalaprilat for treatment of acute hypertensive heart failure in the emergency department. Int J Emerg Med. 2016;9(1):28. This study was a retrospective review of patients with heart failure who received intravenous (IV) enalaprilat; treatment was associated with a significant reduction in blood pressure but an increase in adverse effects at 72 h. CrossRefPubMedCentralPubMedGoogle Scholar
- 34.• Peacock WF, Chandra A, Char D, Collins S, Der Sahakian G, Ding L, et al. Clevidipine in acute heart failure: results of the a study of blood pressure control in acute heart failure–a pilot study (PRONTO). Am Heart J. 2014;167(4):529–36. A randomized, open-label study evaluating IV clevidipine vs standard care in patients presenting with acute heart failure and hypertensive emergency showed that patients receiving clevidipine reached target blood pressure faster and had greater improvement in symptoms. CrossRefPubMedCentralPubMedGoogle Scholar