Step 6: Select appropriate drugs for specific situation

•Pregnancy-induced hypertension

–Preeclampsia, eclampsia, HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome.

–Posterior reversible encephalopathy syndrome (PRES) is a specific hypertensive emergency during pregnancy.

–It is characterized by headache, confusion, seizures, and visual loss.

–It occurs predominantly due to accelerated hypertension and eclampsia.

–For pregnancy-associated hypertensive crises, labetalol, methyldopa, hydralazine, and magnesium sulfate are the drugs of choice.

•Neurologic Hypertensive Emergencies

–Use of a continuous nitroglycerin infusion and nitroprusside should be avoided in the acute management of hypertensive emergencies complicated by cerebral ischemia because these drugs may worsen cerebral perfusion.

–Labetalol or calcium channel blockers are preferred in such a patient population.

•Acute aortic dissection

–Aortic dissection is a life-threatening condition. Upon diagnosis, blood pressure should be reduced to less than 120 mmHg within 20 min. b-Blockers such as labetalol and esmolol as well as sodium nitroprusside along with a beta-blocker can be used.

•Acute coronary syndrome

–The drugs of choice are intravenous nitroglycerin, b-blockers, and angio- tensin-converting enzyme (ACE) inhibitors.

•Acute pulmonary edema

–Treatment of severe hypertension with pulmonary edema requires NTG, diuretics, and ACE inhibitors like captopril.

•Renal emergencies

–Sodium nitroprusside and labetalol are useful.

–Short-term dialysis is sometimes necessary.

–ACE inhibitors may worsen renal function in the setting of bilateral renal artery stenosis, dehydration, or acute renal failure.

•Adrenergic crises

–Examples of adrenergic crises include a pheochromocytoma crisis, cocaine or amphetamine intoxication, and patients on MAO inhibitors ingesting tyraminecontaining food.

–Pure a-blocker like phentolamine is generally prescribed.

–A b-blocker can be added if an additional antihypertensive is required.

Suggested Reading

1.Perez MI, Musini VM. Pharmacological interventions for hypertensive emergencies. Cochrane Database Syst Rev. 2008;23(1):CD003653.

There is insufficient RCT evidence to determine which drug or drug class is most effective in reducing mortality and morbidity.

2.Varon J. Treatment of acute severe hypertension: current and newer agents. Drugs. 2008; 68(3):283–9.

Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages to other available agents in the management of hypertensive crises. Nifedipine, nitroglycerin, and hydralazine should not to be considered first-line therapies in the management of hypertensive crises because these agents are associated with significant toxicities and/or adverse effects.

3.Flanigan JS, Vitberg D. Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat. Med Clin North Am. 2006;90(3):439–51.

Encourage appropriate ongoing follow-up because hypertension is not a single episode; it is an ongoing threat to good health.

4.Vidaeff AC, Carroll MA Acute hypertensive emergencies in pregnancy. Crit Care Med. 2005;33(10 Suppl):S307–12.

Hypertension in pregnancy may be one manifestation of a multiple-system pathologic process, as is the case in preeclampsia. Blood pressure control, along with delivery, will be the first step in treating the renal, hematologic, hepatic, and cardiac dysfunction that can be seen in preeclampsia.

5.Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206–52.

A comprehensive guideline from the experts, which also includes management of hypertensive emergencies.