Drugs used for the treatment of hypertensive emergencies
- William J Elliott, MD, PhD
William J Elliott, MD, PhD
- Professor of Preventive Medicine, Internal Medicine and Pharmacology
- Head, Division of Pharmacology
- Pacific Northwest University of Health Sciences, Yakima, WA
- Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
- Professor of Acute and Continuing Care, The University of Texas Health Science Center at Houston
- Clinical Professor of Medicine, The University of Texas Medical Branch
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
A hypertensive emergency is present when severe hypertension is associated with acute end-organ damage. Examples include hypertensive encephalopathy, acute pulmonary edema, aortic dissection, and rebound after abrupt withdrawal of antihypertensive medications. Immediate but careful reduction in blood pressure is often indicated in these settings. However, an excessive hypotensive response is potentially dangerous, possibly leading to ischemic complications such as stroke, myocardial infarction, or blindness. Thus, in patients who are severely hypertensive but asymptomatic, slower reductions in blood pressure may be achieved with oral agents. (See 'Oral drugs' below.)
The drugs that are used for the treatment of hypertensive emergencies are presented in this topic. The evaluation of patients with severe hypertension and the blood pressure goals in patients with hypertensive emergencies are presented elsewhere. (See "Evaluation and treatment of hypertensive emergencies in adults".)
A variety of parenteral and oral antihypertensive drugs are available for use in these patients (table 1) [1-5]. Few studies have compared these agents with one another, and all are tolerated reasonably well [6,7]. Thus, the drug of choice is often dictated by the type of hypertensive emergency and the local hospital formulary. (See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults" and "Evaluation and treatment of hypertensive emergencies in adults".)
Nitrates — Nitrovasodilators such as nitroprusside and nitroglycerin provide nitric oxide that induces vasodilatation (of both arterioles and veins) via generation of cyclic GMP, which then activates calcium-sensitive potassium channels in the cell membrane .
Nitroprusside — Sodium nitroprusside, when administered by intravenous infusion, begins to act within one minute or less, and once discontinued, its effects disappear within 10 minutes or less. Frequent monitoring is required since this drug can produce a sudden and drastic drop in blood pressure.
- Varon J. Treatment of acute severe hypertension: current and newer agents. Drugs 2008; 68:283.
- Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356:411.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
- Cherney D, Straus S. Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. J Gen Intern Med 2002; 17:937.
- Perez MI, Musini VM. Pharmacological interventions for hypertensive emergencies: a Cochrane systematic review. J Hum Hypertens 2008; 22:596.
- Grossman E, Ironi AN, Messerli FH. Comparative tolerability profile of hypertensive crisis treatments. Drug Saf 1998; 19:99.
- Peacock F, Amin A, Granger CB, et al. Hypertensive heart failure: patient characteristics, treatment, and outcomes. Am J Emerg Med 2011; 29:855.
- Archer SL, Huang JM, Hampl V, et al. Nitric oxide and cGMP cause vasorelaxation by activation of a charybdotoxin-sensitive K channel by cGMP-dependent protein kinase. Proc Natl Acad Sci U S A 1994; 91:7583.
- Schulz V. Clinical pharmacokinetics of nitroprusside, cyanide, thiosulphate and thiocyanate. Clin Pharmacokinet 1984; 9:239.
- Aronson S, Dyke CM, Stierer KA, et al. The ECLIPSE trials: comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients. Anesth Analg 2008; 107:1110.
- Neutel JM, Smith DH, Wallin D, et al. A comparison of intravenous nicardipine and sodium nitroprusside in the immediate treatment of severe hypertension. Am J Hypertens 1994; 7:623.
- Murphy MB, Murray C, Shorten GD. Fenoldopam: a selective peripheral dopamine-receptor agonist for the treatment of severe hypertension. N Engl J Med 2001; 345:1548.
- Peacock WF, Varon J, Baumann BM, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care 2011; 15:R157.
- Hirschl MM, Binder M, Bur A, et al. Clinical evaluation of different doses of intravenous enalaprilat in patients with hypertensive crises. Arch Intern Med 1995; 155:2217.
- PARENTERAL DRUGS
- - Nitroprusside
- - Nitroglycerin
- Calcium channel blockers
- - Clevidipine
- - Nicardipine
- Dopamine-1 agonist
- - Fenoldopam
- Adrenergic-blocking agents
- - Labetalol
- - Esmolol
- Other agents
- - Hydralazine
- - Enalaprilat
- - Phentolamine
- ORAL DRUGS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS