The presentation covers definitions, identification, Treatment goals, Special situations, Practice points, and cardinal pharmacotherapy. Session presented in NBE learning session

1. Hypertensive Crisis :
Detection & Management
Dr Venugopalan P P
DA,DNB,MNAMS,MEM-GW
Director & Lead consultant
Emergency Medicine
Aster Dm Healthcare

2. Disclaimer
I don't have any conflict of interest
to declare in connection with this
presentations. The pictures used
in the presentation in relation to
pharmacotherapy are downloaded
form interment.

3. Hypertensive Crises
Hypertensive crises are acute, severe elevations in blood
pressure that may or may not be associated with target-
organ dysfunction.
Two subsets
1. Hypertensive emergency
2. Hypertensive Urgency

4. Hypertensive emergencies
❏ Acute, severe elevations in blood
pressure Greater than 180/110 mm Hg
❏ Typically with systolic blood pressure
[SBP] greater than 200 mm Hg and/or
diastolic blood pressure [DBP] greater
than 120 mm Hg
❏ Associated with the presence or
impedance of target-organ dysfunction
Muiesan 2015; Mancia 2013; Johnson 2012; Chobanian 2003

5. Hypertensive urgencies
❏ Characterized by an acute elevation
in blood pressure as seen in
Hypertensive emergencies
❏ Not associated with Target-Organ
Dysfunction

6. Risk factors for Hypertensive crisis
❏ Female sex
❏ Higher grades of obesity
❏ Hypertensive heart disease
❏ Coronary heart disease
❏ Mental illness
❏ Nonadherence to
antihypertensive medications
Saguner 2010

7. Risk factors for Hypertensive crisis
Intoxications
❏ Cocaine
❏ Amphetamines
❏ Phencyclidine
hydrochloride
❏ Stimulant diet
supplements
Withdrawal
syndromes
❏ Clonidine
❏ β-antagonists
Johnson 2012; Aggarwal 2006;
Shea 1992

8. Risk factors for Hypertensive crisis
Drug-drug/Drug- food
interactions
❏ Monoamine oxidase
inhibitors
❏ Tricyclic antidepressants
❏ Antihistamines
❏ Tyramine
Johnson 2012; Aggarwal 2006;
Shea 1992

9. Risk factors for Hypertensive crisis
❏ Spinal cord disorders
❏ Pheochromocytoma
❏ Pregnancy
❏ Collagen vascular
disease (Systemic
Lupus Erythematosus)
Johnson 2012; Aggarwal 2006; Shea 1992
1200 × 675

10. Blood pressure Systolic mm
of Hg: Upper
number
Diastolic mm of Hg
: Lower number
Normal Less than 120 And Less than 80
Elevated 120-129 And Less than 80
High Blood pressure
( Hypertension) Stage 1
130-139 Or 80 - 89
High Blood pressure
( Hypertension)Stage 2
140 or Higher Or 90 or Higher
Hypertensive Crisis Higher than 180 And / or Higher than 120

12. Auto Regulation
Failure
Blood pressure
Vascular
Resistance
Vasoconstriction
Hypertensive crisis
Pathophysiology

13. Prothrombotic
state
Vasoconstriction
Ischemia
Target Organ Damage (TOD)
RAAS ActivationEndothelial Injury
Hypertensive crisis
Pathophysiology

14. Hypertensive emergencies

15. Some organs are affected more ?
Any target organ can be affected by acute, severe,
uncontrolled hypertension
Some organs are more commonly affected than others
1. Differences in the amount of cardiac output received
2. Total oxygen consumption
3. Autoregulatory capacity (Autoregulatory dependence)

16. Tests in hypertensive crisis
❏ Blood pressure
measurement in both
arms
❏ Urine toxicology
screen
❏ Funduscopic
examination
❏ Serum glucose

17. Tests in hypertensive crisis
❏ Creatinine
❏ Electrolytes
❏ CBC
❏ Liver function tests
❏ Urinalysis (Proteinuria and
hematuria)

18. Tests in hypertensive crisis
❏ Chest radiography
❏ ECG
❏ Echocardiography
❏ Urine or serum pregnancy
screening
❏ Head CT
❏ Chest CT (Muiesan 2015 )

19. Hypertensive crisis :
Treatment Goals

20. Treatment goal in hypertensive
crisis depends...
Classification
Emergency vs. Urgency
Presenting conditions
❏ Unique treatment goals
Time to goal
❏ Additional treatment
parameters
❏ Treatment modalities

21. General treatment
The general treatment of
hypertensive crisis, patients should
be classified as having
Hypertensive Emergency or
Hypertensive Urgency

22. “Compelling conditions” are an exception
for general treatment principles
“Hypertension may exist in association with
other conditions in which there are
compelling indications for use of a
particular treatment based on clinical trial
data demonstrating benefits of such therapy
on the natural history of the associated
condition”
Whelton 2017

23. Compelling Indications in
Hypertension management
● Heart failure
● Post Myocardial infarction
● High CAD Risk
● Diabetes
● Chronic Kidney disease
● Recurrent stroke prevention
Whelton 2017

24. Hypertensive Urgency
❏ Requires initiating, reinitiating,
modifying, or titrating oral
therapy
❏ Does not require ICU or hospital
admission

25. Hypertensive Urgency : Treatment
target
❏ Gradual blood pressure reduction
over 24–48 hours
❏ Common error : Over aggressive
correction
❏ No benefit
❏ Harmful due to rapid decrease of
BP

26. Autoregulation

27. Shift of Autoregulation curve

28. Chronic Hypertension - Present
with urgency
❏ End organs adapt to chronically elevated blood
pressures, setting a new physiologic “norm” of
autoregulation
❏ New “norm” leads to optimal organ perfusion at a
higher baseline blood pressure

29. If this autoregulatory shift is
unrecognized during a hypertensive
crisis, patients may be at risk of
harm from overcorrection or over-
normalization of blood pressure.

30. Hypertensive Emergency
Identify
❏ General treatment
category
❏ “Compelling”
conditions category
Aortic
Dissection
Acute
Stroke
Pregnancy

31. Treatment goal decision- Algorithm in
Hypertensive crisis

32. Acute elevation in BP -
Hypertensive crisis
Signs of End Organ
Dysfunction?
Hypertensive Emergency Hypertensive Urgency
1. Physical
Exam
2. Lab tests
3. Diagnostic
Exams
Yes No

33. Hypertensive Emergency
Exception to general
treatment goal?
General
Hypertensive
Emergency
Stroke
Aortic
dissection
Pre-eclampsia/Eclampsia
No
Yes
Treatment goal Decision
Algorithm

34. Goal Time BP Target
First hours Reduce MAP by 25%( While maintaining goal DBP more
than 100 mm Hg
Hours 2 to 6 SBP 160 mm Hg and DBP 100-110 mm Hg
Hours 6 to 24 Maintain goal for 2-6 during first 24 hours
Hours 24 to 48 Outpatient BP goals according to the 2017 Guidelines for
management of High Blood Pressure in Adults
BP Treatment Goals for Hypertensive
Emergency

35. Unique treatment goals to be
followed in the following conditions
❏ Aortic dissection
❏ Acute stroke - Ischemic and
Hemorrhagic
❏ Pre-eclampsia/ Eclampsia
❏ Hypertensive emergency in
pregnancy

36. Aortic Dissection
Classified on the basis of Anatomic location and
Involvement of the aorta
Stanford classification
❏ Type A - Ascending aorta with or without distal aorta
involvement
❏ Type B- Only the aortic arch or descending aorta

37. Acute Aortic Dissection

38. Aortic Dissection as a Surgical
Emergency
1. Type A
2. Life-threatening type B
Hiratzka 2010
❏ Malperfusion syndrome
❏ Rapidly progressing
dissection
❏ Enlarging aneurysm
❏ Inability to control blood
pressure
❏ Uncontrolled symptoms
with medications

39. Non-Life threatening Type B Aortic
Dissection
❏ First line : Medical management
❏ Propagation of the aortic dissection is
related to shear stress (A principle
related to blood flow velocity and rate)
❏ Treatment goal for aortic dissection is 2-
fold: Blood Pressure and Heart Rate
control

40. Treatment Goal
1. Heart rate goal: less than 60 beats/minute within
minutes of presentation
2. Blood pressure after achieving adequate heart rate
control is SBP less than 120 mm Hg and/or as low as
clinically tolerated
❖ Lowest blood pressure that maintains end- organ
perfusion- Clinical toleration

41. Acute ischemic stroke
❏ Hypertension associated with ischemic
stroke is often considered an adaptive
response to maintain cerebral perfusion
pressure (CPP) to the brain
❏ Ischemic strokes can be associated with
increases in ICP
❏ Acute treatment of MAP elevations is
only indicated in limited circumstances

42. Cerebral perfusion pressure
CPP is equal to the
difference between MAP
and intracranial pressure
(ICP)
[CPP = MAP − ICP].

43. Indications for Acute treatment
1. Use of thrombolytic therapy
2. Other target-organ damage (e.g., aortic
dissection, myocardial infarction)
3. “Severe” elevations in blood pressure (SBP
greater than 220 mm Hg and/ or DBP
greater than 120 mm Hg)
Jauch 2013

44. Treatment goal in Thrombolytic
therapy
❏ Blood pressure goal before initiating thrombolysis is
less than 185/110 mm Hg
❏ After commencement and throughout thrombolysis,
and for the subsequent 24 hours, the BP goal is less
than 180/105 mm Hg
❏ Fewer intracerebral hemorrhages (ICHs) associated
with intravenous thrombolysis

45. Ischemic stroke with other TOD
and Severe Elevations
1. The BP goal is a more modest reduction of 15% (10%–
20%) in the MAP over 24 hours
2. Allowing for maintenance of CPP
3. Avoiding the complications of cerebral edema
exacerbation and hemorrhagic transformation
Figueroa 2015; Johnson 2012; Hiratzka 2010, Whelton 2017

46. Acute Hemorrhagic stroke
❏ Increase ICP,
potentially
compromising
CPP
❏ Acute
hypertension in
this setting will
be adaptive
(Strandgaard 1976; Symon 1973; Lassen 1959).
High BP during acute ICHs
1. Hematoma expansion
2. Neurologic deterioration
3. Inability to perform
activities of daily living
4. Death

47. Acute Hemorrhagic stroke
❏ Hyperacute (less than 3 hours)
and acute (less than 4.5 hours)
treatment of patients with ICH
without ICP elevations
❏ Target SBP goal of less than 160
mm Hg over the first few hours is
relatively safe

48. Acute Hemorrhagic stroke
❏ Modest reduction
to SBP less than
180 mm Hg or
MAP less than
130 mm Hg over
the first 24 hours
1. “Severe” elevations
in blood pressure
(e.g., SBP greater
than 220 mm Hg)
2. Large hematomas
3. Known elevations in
ICP

49. Hypertensive emergencies in
Pregnancy
Pregnancy-associated categories
1. Chronic hypertension
2. Gestational hypertension
3. Pre- eclampsia
4. Chronic hypertension with superimposed preeclampsia
5. Non–pregnancy- associated hypertensive emergencies
in the pregnant patient

50. Risks associated with Hypertensive
emergencies in Pregnancy
Maternal
1. Acute renal failure
2. Placental abruption
3. Cerebrovascular accident
4. Myocardial infarctions
5. Respiratory distress
Fetal
1. Preterm birth
2. Low birth weight
3. Fetal demise

51. Acute Hypertension definitions in the
pregnant patients

52. Name BP criteria Additional Criteria
“Severe” Acute
Hypertension
SBP more than 160 mm Hg or DBP more than 110 mm of Hg
Preeclampsia SBP More than 140 mm of Hg or DBP more than 90 mm of Hg ❏ BP reading must occur on more
than 2 occasion in 4 hrs apart
❏ More than 20 wk gestation
Either
❏ Proteinuria( 24 hours collection
more than 300 mg or Spot urine
collection U protein/UCr more than
0.3mg/dl)
❏ Severe features
Eclampsia Preeclampsia degree of BP elevation New onset of Grand Mal seizures in a
woman with no known seizures disorders
HELLP syndrome With or without preeclampsia degree of BP elevation ❏ Hemolysis
❏ Elevated Liver enzymes (
AST/ALT more than 70 IU/L
❏ Low platelet ( Less than 1,00,000)
Hypertensive
Emergency
BP more than 240/140 mm Hg

53. Preeclampsia and pregnancy
related Hypertension
❏ Blood pressure elevations are considered the only
modifiable target of therapy similar to hypertensive
emergency (CMACE 2011)
❏ Target goal for hypertensive emergency and
preeclampsia is less than or equal to 160/110 mm Hg
❏ Avoid abrupt decreases in blood pressure which can
lead to potential harmful fetal effects (Vidaeff 2005)

54. Preeclampsia and Pregnancy
related Hypertension
1. MAP should be decreased by 20%–25% over the
first few minutes to hours
2. Blood pressure further decreased to the target
of 160/110 mm Hg or less over the subsequent
hours (ACOG 2013; Vidaeff 2005)

55. Blood Pressure Variability-BPV

56. Blood Pressure Variability-BPV
An emerging therapeutic
consideration for the
treatment of hypertensive
emergency is the concept of
Blood Pressure Variability
(BPV)
Definition
BPV is a standardized
way of representing
changes in blood
pressure over time
(Parati 2013)

57. Variabilities in SBP and DBP
1. Inherent - related to
Cardiac cycle
2. Beat-to-beat
3. Diurnal
4. Physiologic
(Schillaci 2012; Mancia 2000; Mancia 1986;
Conway 1984).
Interplaying Factors
1. Humoral
2. Behavioral
3. Environmental

58. BPV

59. BPV

60. Blood pressure Vaiability Indexes
Index Variables Description
Standard
Deviations(SD)
Computed as the square root of mean of the squares of the deviations from the
arithmetic mean over the sample ( eg 24 hrs)
Coefficient of
Variations(CoV)
Computed as the SD divided by the mean
Average Real
Variability(ARV)
Computed as the average of the absolute differences between consecutive BP
measurements over time
Residual BPV Computed in the frequency domain through spectral analysis of BP fluctuations over
time ( eg 24 hrs )
Weighted 24 hr SD Computed by weighting the average of daytime and nighttime BP SD for the duration of
the day and nighttime periods and averaging the SD of these two sub-periods

61. BPV
Absolute average blood pressure
lowering, may be associated with
cardiovascular protection,
including protection from stroke,
myocardial infarction, and both
cardiovascular and all-cause
mortality
(Hashimoto 2012; Johansson 2012; Rothwell 2010)
BPV profiles between
medication classes
differ significantly
(Ishikura 2012; Rothwell)

62. BPV
❏ During the acute phase of stroke, blood pressure
regulation is impaired, leading to blood pressure
elevation and lability (Sykora 2008)
❏ The exact mechanism for this finding is currently
unknown, but it is thought to be related to impairment in
the baroreflex (Henderson 2004).

63. Prognostic significans of BPV
❏ Correlation between decreased BPV and improved early
neurologic function (Rodriguez- Luna 2013)
❏ Favorable neurologic recovery (Tanaka 2014)
❏ Decreased incidence of death or major disability (Manning
2014)

64. Few real concerns ...Yet to answer
1. How do we measure BPV at the bedside in real-time?
2. Which measure of BPV correlates best with outcomes
and do the various measures of BPV correlate with one
another?
3. Are these findings consistent in other populations with
hypertensive emergency?
4. What is the exact therapeutic target and timing of
decreasing BPV?
5. How does medication selection affect BPV?

65. Pharmacotherapy in Hypertensive
Emergencies

66. Pharmacotherapy in Hypertensive
emergency
1. Affected target organ on
presentation
2. Pharmacokinetics (PK)
3. Pharmacodynamics (PD)
4. Hemodynamic
5. Adverse effect
6. BPV profile
Choice of
medication

67. Pharmacotherapy in Hypertensive
Emergency
1. Intravenous administration
2. Ability to be titrated to
desired effect
3. Allowing for a “smooth”
reduction of blood pressure
4. Short duration of activity
5. Minimal adverse effect
profile
Preferable
traits of
medications
used in
hypertensive
emergencies

68. Pharmacotherapy in Hypertensive
Emergency
❏ Extreme caution: Avoid acute and profound lowering of
blood pressure
❏ Over-normalization induces ischemic complications
(Strandgaard 1984)
❏ 10%–66% of patients may have over-normalization of
blood pressure
❏ Challenge: Goal of smooth, target-associated blood
pressure reduction

69. Medications in Hypertensive
Emergency
1. Vasodilators
2. Calcium channel blockers
3. Beta Blockers
4. ACEI
5. Alpha Antagonists
6. D1 Receptor Agonists

70. Vasodilators
Agent Dosages Onset Duration Preload Afterload Cardiac
output
Hydralazine IV: Bolus :10-20 mg
IM :10-40mgq30mt
PRN
IV- 10mt
IM -20mt
IV:1 -4 hrs
IM : 2- 6 hrs
Nitroglycerine IV : 5 to 200 mcg/mt
Titrate 5-25 mcg/mt
q5-10mts
2-5mts 5-10mts
Sodium
Nitroprusside
IV- 0.25 to 10
mcg/kg/mt
Titrate 0.1 to
0.2mcg/kg/mt q5mts
Seconds 1-2mts

71. Calcium channel blockers
Agent Dosages Onset Duration Preload Afterload Cardiac
output
Clevidipine IV: 1 to 6 mg /hr
Titrated by 1 to 2
mg/hr q 90s; Max
32 mg/ hr
1 to 4 mt 5 to 15 mt
Nicardipine IV- 5 to 15 mg/hr
Titrate by 2.5mg/hr
q5-10mts
5 to 10
mts
2 to 6 hrs

72. Beta Blockers
Agent Dosages Onset Duration Preload Afterload Cardiac
output
Esmolol IV: 25 to 300 mcg/kg/mt
Titrated by 25 mcg/kg/mt
,q3- 5 mts
1-2 mts 10 to 20 mts
Labetalol IV bolus ; 20mg ,Repeat
escalating doses of 20-
80mg,q 5-10mts
PRN.Titrate 1-2mg/mt
q2hr
2-5mts
Peak 5
to 15
min
2 -6 hrs
Upto 18 hrs
Metoprolol IV- bolus:5-15mgq5-15mts
PRN
5-20mt 2 - 6 hrs

73. ACEI,Alpha Antagonist & D1 Agonists
Agent Dosages Onset Duration Preload Afterload Cardiac
output
ACEI:
Enalaprilat
IV: Bolus:1.25mg q6hr,
Titrate mo more than
112-14hr,
Max 5 mg q6hr
15-30 mts 12 to 24 hrs
Alpha-
Antagonist:
Phentolamine
IV bolus: 1 -5 mg PRN
Max 15mg
Seconds 15 mts
D1 Agonists
Fenoldopam
IV-0.03-1.6mcg/kg/mt
Titrate by 0.05-1
mcg/kg/mt, q15mts
10-15 mts 10 -15 mts

74. A
B
C
D
ACEI, Alpha Antagonist , Agonists of DI
Beta Blockers
Calcium Channel blockers
Dilators of Vessels ( Vasodilators)
Drugs used
in
Hypertensive
Emergency

75. Hydralazine
❖ Indicated in Pregnancy
Adverse effects
❏ Prolonged hypotension
❏ Reflex tachycardia
❏ Headache
❏ Lupus like syndrome(
Long term use)

76. Nitroglycerine
Indications
❏ Coronary
ischemia
❏ Infarction
❏ Acute left
ventricular
failure
❏ Pulmonary
edema
Issues
❏ Tachyphylaxis
❏ Requiring frequent
dose titrations
Adverse effects
❏ Flushing
❏ Headache
❏ Erythema
❏ Venous greater than
arterial vasodilator

77. Sodium Nitroprusside
Indications
Most of the
scenarios
Excluding
● ICP elevations
● Coronary
infarction
● Ischemia
Special consideration
❏ Liver failure – Cyanide
accumulation
❏ Renal failure – Thiocyanate
accumulation
❏ Can obtain serum cyanide and
thiocyanate concentrations
❏ Toxicity associated with
prolonged infusions (> 72 hr)
❏ High doses (> 3 mcg/kg/min)
❏ Coronary steal
❏ Increases ICP

78. Clevidipine
Indications
❏ Acute
ischemic
stroke
❏ Hemorrhagic
stroke
Special
Considerations
❏ Formulated in oil-in-
water
❏ Formulation providing 2
kcal/mL of lipid calories
❏ Caution for patients
with soya or egg allergy
❏ Risk of reflex
tachycardia

79. Nicardipine
Indications
❏ Acute
ischemic
stroke
❏ Hemorrhagic
stroke
Special
consideration
❏ Risk of reflex
tachycardia
❏ Infusion can
lead to large
volumes
administered

80. Esmolol
Indications
❏ Aortic
dissection
❏ Coronary
ischemia
❏ Infarction

81. Esmolol: Special consideration
❏ Contraindicated in acute decompensated heart
failure
❏ Should be used in conjunction with an arterial
vasodilator for BP management in aortic
dissection
❏ Initiate esmolol first because of its delayed onset
relative to vasodilators such as sodium
nitroprusside
❏ Metabolism is organ-independent
❏ Hydrolyzed by esterases in blood
❏ Useful in tachyarrhythmias

82. Labetalol
Indications
❏ Acute ischemic stroke h
❏ Acute Hemorrhagic
stroke
❏ Aortic dissection
❏ Coronary
ischemia/infarction
❏ Pregnancy

83. Labetalol : Special considerations
❏ May be used as monotherapy in acute
aortic dissection
❏ Contraindicated in acute
decompensated heart failure
❏ Prolonged hypotension may occur with
overtreatment
❏ Dosing cautiously α/β = 1/7

84. Metoprolol
Indications
❏ Aortic dissection
❏ Coronary
ischemia/infarction

85. Metoprolol : Special considerations
❏ Contraindicated in acute decompensated heart
failure
❏ Should be used in conjunction with an arterial
vasodilator for BP management in aortic
dissection
❏ Initiate metoprolol first because of its delayed
onset relative to vasodilators such as sodium
nitroprusside
❏ Useful in tachyarrhythmias

86. Enalaprilat
Special
considerations
❏ Contraindicated
in pregnancy
❏ Cautious dosing;
prolonged
duration of
action
Indication
❏ Acute Left
Ventricular
Failure

87. Phentolamine
Special considerations
❏ Use in catecholamine-induced
hypertensive emergency
❏ Cocaine-induced HTN crisis – use
in conjunction with BZDs
Indication
❏ Catecholamine excess
(Pheochromocytoma)

88. Fenoldopam
It can be used
almost all
scenarios

89. Fenoldopam:Special considerations
❏ Caution in increased ICP
❏ Caution in intraocular pressure
❏ Risk of reflex tachycardia
❏ Cause hypokalemia, flushing
❏ Worsen glaucoma
❏ Unique MOA: D1 specific agonist –
Peripheral vasodilation

90. Guidelines & Recommendations

91. The medical management of acute aortic
dissection recommend β-blockers to reduce the
force of ventricular ejection (which can worsen
shear stress) and, if additional blood pressure
lowering is needed to meet the goal of SBP less
than 120 mm Hg (ideally less than 100 mm Hg),
use of a vasodilator
(Erbel 2014; JCS Joint Working Group 2013; Hiratzka 2010; Erbel 2001)

92. Acute ischemic stroke, the guidelines do
not recommend a single specific agent
or class of agents but state that an
individualized approach is most
appropriate, with consideration of
agents such as labetalol, nicardipine,
hydralazine, and enalaprilat
(Jauch 2013)

93. Acute Hemorrhagic Stroke :
❏ Guidelines are silent on which agents
to use for the early aggressive
reduction of blood pressure, but
referenced literature in the guidelines
predominantly used nicardipine as a
primary agent (Hemphill 2015)
❏ Because of the importance of BPV in
this population, nicardipine and
clevidipine may be considered
preferential agents in this population

94. ❏ Acute, severe hypertension related
to pregnancy, specific agents
(hydralazine, labetalol, and CCBs
[e.g., nicardipine]) are recommended
❏ The guidelines recommend
selecting an agent on the basis of
adverse effects, contraindications,
and
clinician experience with that agent
(ACOG 2013)

95. Cocaine-induced hypertension:
❏ Benzodiazepines are an effective first-
line therapy, but additional blood
pressure control may be warranted
(Richards 2006).
❏ Blood pressure control: α-blocking
agents (e.g., phentolamine),
dihydropyridine , CCBs (e.g.,
nicardipine and clevidipine), and nitric
oxide–mediated vasodilators (e.g.,
sodium nitroprusside and
nitroglycerin) are effective

96. ❏ Concurrent tachycardia is
present, added combination
α/β-blockers (e.g., labetalol)
are safe and effective
(Richards 2006)
❏ β-Selective antagonists
should be avoided as initial
monotherapy

97. Hypertensive emergency caused
by Pheochromocytoma,
Phentolamine is largely
considered the drug of choice
(Prejbisz 2011)
Acute presentations of heart failure (left heart
failure with pulmonary edema or right heart failure
with systemic edema), nitroglycerin is the drug of
choice

98. ❏ Concurrent loop diuretics should
also be administered with
considerations for renal
replacement therapy, as needed, for
volume removal (Rhoney 2009)

99. Practice Points

100. ● The first step in assessing a patient for hypertensive
crisis is determining the presence or absence of
target-organ damage
● Target-organ damage assessment often stems from
patient-specific chief concerns, physical examination
findings, routine and directed laboratory test
assessments, and use of diagnostic examinations

101. ❏ After patients are confirmed to have a
hypertensive emergency, they must be screened
for exceptions (e.g., stroke, pregnancy-
associated acute hypertension, and aortic
dissection) to the general principles of treatment,
which will allow for target goal development
❏ In general hypertensive emergencies (i.e., without
exceptions), the goal in the first 60 minutes of
treatment is to reduce the MAP by 25%

102. ❏ Patients with exceptions have unique treatment
goals leading to unique medication selection
❏ The goal of medication selection is to provide
“smooth” blood pressure reduction, optimizing
BPV with agents that are readily titrated while
avoiding complications because of adverse
effects
❏ Knowledge of the PK, PD, hemodynamics, and
adverse effect profiles of the available options is
warranted.

103. References