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Antihypertensive Therapy for Hypertensive Emergencies

Terapi Anti Hipertensi Untuk Hipertensi Emergensi 

Patients with severe hypertension (> 220/120 mm Hg) and signs and symptoms of encephalopathy, acute myocardial ischemic syndromes, stroke, pulmonary edema, or aortic dissection should be treated emergently to achieve rapid reduction of their blood pressure. Because of its rapid onset and short duration of therapy, which allow for smoother titration of blood pressure, intravenous sodium nitroprusside is the treatment of choice. Patients should be admitted to the intensive care unit and monitored closely during therapy. The aim is to reduce blood pressure very quickly within the first hour or two after presentation but to avoid hypotension. Patients must be monitored for thiocyanate toxicity if therapy is prolonged. An alternative is intravenous fenoldopam, a selective dopamine-1 receptor agonist. It has a similar antihypertensive profile to nitroprusside with a rapid predictable onset of action, short half-life (9.8 min), and few side effects at effective doses. There is a linear correlation between fenoldopam infusion rate and blood pressure lowering. Its use still requires monitoring in the intensive care unit. 

Antihypertensive Therapy for Hypertensive Emergencies
Drug Dose Comments
Nitroprusside 0.25–10 mcg/kg/min Treatment of choice
Fenoldopam 0.1 mcg/kg/min, increased by 0.05 mcg/kg/min Does not require thiocyanate monitoring
Labetalol 20–40 mg IV q10 min to 300 mg Commonly used after surgery
Esmolol 500 mcg/kg over 1 min, then 25–200 mcg/kg/min Can aggravate heart failure
Clonidine 0.1–0.2 mg PO, 0.05–0.1 mg qh until 0.8 mg Sedation possible
Captopril 6.25–50 mg PO q 6–8 h Excessive hypotension possible

If aortic dissection is present, a short-acting beta-blocker such as esmolol should be added to decrease shear forces in the aorta. Intravenous labetalol is highly effective and can also be used. Oral immediate-release clonidine and ACEI are effective in rapidly reducing blood pressure and can be added orally. Oral immediate-release nifedipine may cause unpredictable hypotension and should not be used.

Current Diagnosis & Treatment Cardiology 3rd Edition (McGraw-Hill) 2009

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