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:

Clonidine Captopril Labetalol

Dose 0.2 mg PO initial, 0.1 6.25–50 mg PO* 100–300 mg po q2-
mg Q1H 3hrs or 200-400 mg PO
Max = 0.8 mg Q2-3H
Onset 30 minutes-2 hrs 15 minutes 30 minutes-2 hrs
Duration 6-8 hrs 4-6 hr 4 hrs
Side Sedation, dry mouth, Rash, pruritus, Orthostatic
Effects dizziness proteinuria, loss of hypotension, nausea,
taste, hypotension vomiting
Caution Altered mental status, RAS, hyperkalemia, CHF, asthma,
severe carotid artery dehydration, renal bradycardia, heart
stenosis failure, pregnancy block
Note *SL administration has Response rates not
been reported and may always predictable
be used.
RAS = Renal Artery Stenosis, SL = sublingual, CHF = Congestive Heart Failure
 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 Preferred Treatment Avoid

Severe Hypertension
Heart Failure Nitroprusside Labetolol
Renal Insufficiency Nitroprusside Fenoldopam*
Acute Coronary Ischemia Nitroglycerin, Labetolol, Hydralazine
Nitroprusside
Cerebrovascular Accident Labetolol Nitroprusside, Nitroglycerin
Eclampsia Hydralazine, Labetolol Nitroprusside
Aortic Dissection Nitroprusside + beta Hydralazine, ACE inhibitors
blocker
*
See restrictions for Fenoldopam
 Drug Dose/ Onset of Duration Side Caution Monitoring Note
Route Action of Effects
Action
Nitroprusside 0.25 Seconds 3-5min Cyanide and Pregnancy, Continuous Considered first line
mcg/kg/min thiocyanate increased intra-arterial BP ↑ dose slowly by 0.25
-8 toxicity, intracranial Cyanide ug/kg/min; Max 10
mcg/kg/min hypotension pressure, toxicity (MS mcg/kg/min; If BP control not
IV renal failurechange, coma achieved within 10 min of max
metabolic rate, D/C gtt
status, lactic Cyanide toxicity usually seen
acidosis, at infusion > 3 mcg/kg/min
seizures, smell
of almonds)
Fenoldopam 0.1-0.3 < 5 min 30 min Headache, Glaucoma, BP, Serum Restricted for patients:
mcg/kg/min flushing, intraocular electrolytes, With pre-existing renal
↑ dosage dizziness, hypertension (low K+) insufficiency (SCr> 2)
by 0.05-0.1 tachycardia With hepatic dysfunction
mcg/kg/min (INR>1.5, Bil >3,
q15 min 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
Labetolol 2 mg/min ≤ 5 min 3-6 hr Orthostatic Asthma, Orthostasis, BP Use in patients with
IV or 20-80 hypotension, bradycardia, underlying CAD, acute MI,
mg Q10 abdominal heart block, angina, or following vascular
min up to pain, decompensa surgical procedures.
Max dose dizziness, ted CHF May be useful in patients
300 mg nausea, with cerebrovascular disease.
vomiting, May use in patients with
diarrhea eclampsia
 Drug Dose/ Onset of Duration Side Caution Monitoring Note
Route Action of Effects
Action
Hydralazine 10-20 mg 10-30 2-6 Angina, Coronary Use in patients with
IV min (IV) hours tachycardia, ischemia, eclampsia
10-50 mg 20-40 headache angina, MI, Rarely used to treat crises
IM min (IM) aortic because of unpredictable
dissection response. Avoid use.
Nitroglycerin 5-100 2-5 min 5-10 min Methemoglo Pericardial Preferred in patients with
mcg/min IV after D/C binemia, tamponade, coronary ischemia, unstable
infusion infusion headache, pericarditis, angina, acute MI
tachycardia, increased
nausea, intracranial
vomiting, pressure
flushing,
tolerance
with
prolonged
use
Esmolol 250-500 µ 1 – 2 min 10–20 Thrombophl Asthma, BP, heart rate May be used for
g/kg/min for min ebitis, bradycardia, perioperative HTN and aortic
1 min then hypotension, heart block, dissection
50 – 100 µ nausea decompensa Use for ≤ 24 hours
g/kg/min for ted CHF
4 min; may
repeat
sequence