Nonpharmacologic Management

• Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
  • In Adults with Hypertension Who are Overweight/Obese, Weight Loss is Recommended to Decrease Blood Pressure (Class of Recommendation: I, Level of Evidence: A)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 5 mm Hg
  • In Adults with Hypertension, a Heart-Healthy Diet, Such as the DASH (Dietary Approaches to Stop Hypertension) Diet, Which Facilitates Achieving a Desirable Weight is Recommended (Class of Recommendation: I, Level of Evidence: A)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 11 mm Hg
  • In Adults with Hypertension, Dietary Sodium Reduction is Recommended (Class of Recommendation: I, Level of Evidence: A)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 5-6 mm Hg
  • In Adults with Hypertension, Potassium Supplementation Preferably as Part of a Dietary Modification) is Recommended (Unless Contraindicated by the Presence of Chronic Kidney Disease or Use of Medications Which Decrease potassium Excretion (Class of Recommendation: I, Level of Evidence: A)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 4-5 mm Hg
  • In Adults with Hypertension, Increased Physical Activity with a Structured Exercise Program is Recommended (Class of Recommendation: I, Level of Evidence: A)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 4-8 mm Hg
  • In Adults with Hypertension Who Currently Consume Alcohol, Patients Should Be Advised to Drink No More than 2 and 1 Standard Drinks Per Day, Respectively (Class of Recommendation: I, Level of Evidence: A)
    • 1 “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol)
    • Approximate Impact on Systolic Blood Pressure in the Setting of Hypertension: 4 mm Hg

Timing of Initiation of Antihypertensives

• Study of Optimal Timing of Systolic Hypertension Treatment (Using STEP Trial Data) (Hypertension, 2024) [MEDLINE]: n = 8,442
  • Each 1 yr Increase in Hypertension Duration Continuously Increased the Adjusted Risk of Major Cardiovascular Events by 4% (95% CI: 1.01-1.08) Up to 20 yrs, Plateauing at an Adjusted Hazard Ratio of 2.27 (95% CI: 1.28-4.04)
  • After Intensive Systolic Blood Pressure Treatment, the Incidences of Major Cardiovascular Events were Similar Across Different Hypertension Duration Groups, Which were 2.22%, 1.69%, 3.02%, and 2.52%, Respectively (P > 0.05)
  • Initiating Intensive Systolic Blood Pressure Treatment at Any Stage of Hypertension Duration Could Decrease Cardiovascular Disease Risk to a Comparable Level

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults) (Hypertension, 2018) [MEDLINE]

• Classification of Blood Pressure
  • Blood Pressure Should Be Categorized into One of the Categories, Facilitating Prevention and Treatment of Hypertension (Class of Recommendation: I, Level of Evidence: B-NR)
    • Normal
      • Systolic Blood Pressure (SBP) <120 mm Hg and Diastolic Blood Pressure (DBP) <80 mm Hg
    • Elevated Blood Pressure
      • Systolic Blood Pressure (SBP) 120-129 mm Hg and Diastolic Blood Pressure (DBP) <80 mm Hg
    • Stage 1 Hypertension
      • Systolic Blood Pressure (SBP) 130-139 mm Hg or Diastolic Blood Pressure (DBP) 80-89 mm Hg
    • Stage 2 Hypertension
      • Systolic Blood Pressure (SBP) ≥140 mm Hg or Diastolic Blood Pressure (DBP) ≥90 mm Hg
• Blood Pressure Treatment Thresholds
  • Use of Antihypertensives is Recommended for Secondary Prevention of Recurrent Cardiovascular Disease Events in Patients with Clinical Cardiovascular Disease and an Average Systolic Blood Pressure of ≥130 mm Hg or an Average Diastolic Blood Pressure of ≥80 mm Hg, and for Primary Prevention in Adults with an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk of ≥10% and an Average Systolic Blood Pressure ≥130 mm Hg or an Average Diastolic Blood Pressure ≥80 mm Hg (Class of Recommendation: I, Level of Evidence: SBP: A, DBP: C-EO)
    • Whereas Treatment of Hypertension with Antihypertensives on the Basis of Blood Pressure Level Alone is Considered Cost-Effective, the Use of a Combination of Absolute Cardiovascular Disease Risk and Blood Pressure Level to Guide Antihypertensive Therapy is More Efficient and Cost-Effective at Decreasing the Risk of Cardiovascular Disease than Use of the Blood Pressure Level Alone
  • Use of Antihypertensives is Recommended for Primary Prevention of Cardiovascular Disease in Adults with No History of Cardiovascular Disease and with an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk <10% and an Systolic Blood Pressure ≥140 mm Hg or a Diastolic Blood Pressure ≥90 mm Hg (Class of Recommendation: I, Level of Evidence: C-LD)
• Follow-Up After Initial Blood Pressure Evaluation
  • Adults with an Elevated Blood Pressure or Stage 1 Hypertension Who Have an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk <10% Should Be Managed with Nonpharmacological Therapy and Have a Repeat Blood Pressure Evaluation within 3-6 mos (Class of Recommendation: I, Level of Evidence: B-R)
  • Adults with Stage 1 Hypertension Who Have an Estimated 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Risk of ≥10% Should Be Managed Initially with a Combination of Nonpharmacological and Antihypertensive Therapy and Have a Repeat Blood Pressure Evaluation in 1 mo (Class of Recommendation: I, Level of Evidence: B-R)
  • Adults with Stage 2 Hypertension Should Be Evaluated by or Referred to a Primary Care Provider within 1 mo of the Initial Diagnosis, Have a Combination of Nonpharmacological and Antihypertensive Therapy (with 2 Agents of Different Classes) Initiated, and Have a Repeat Blood Pressure Evaluation in 1 mo (Class of Recommendation: I, Level of Evidence: B-R)
  • For Adults with a Very High Average Blood Pressure (i.e. Systolic Blood Pressure ≥180 mm Hg or DBP ≥110 mm Hg), Evaluation Followed by Prompt Antihypertensive Therapy is Recommended (Class of Recommendation: I, Level of Evidence: B-R)
  • For Adults with a Normal Blood Pressure, Repeat Evaluation Every Year is Reasonable (Class of Recommendation: IIa, Level of Evidence: C-EO)
• General Principles of Antihypertensive Therapy
  • In Adults with Hypertension, Simultaneous Use of an ACE Inhbiitor, ARB, and/or Renin Inhibitor is Potentially Harmful and is Not Recommended (Class of Recommendation: III-Harm, Level of Evidence: A)
• Recommended Blood Pressure Goals
  • For Adults with Confirmed Hypertension and Known Cardiovascular Disease or 10-Year Atherosclerotic Cardiovascular Disease (ASCVD) Event Risk of ≥10%, a Blood Pressure Target of <130/80 mm Hg is Recommended (Class of Recommendation: I, Level of Evidence: SBP: B-R, DBP: C-EO)
  • For Adults with Confirmed Hypertension, without Additional Markers of Increased Cardiovascular Disease Risk, a Blood Pressure Target of <130/80 mm Hg May Be Reasonable (Class of Recommendation: IIb, Level of Evidence: SBP: B-NR, DBP: C-EO)
• Choice of Initial Antihypertensive Medication
  • For Initiation of Antihypertensive Therapy, First-Line Agents include Thiazide Diuretics, Calcium Channel Blockers, and ACE Inhibitors or ARB’s (Class of Recommendation: I, Level of Evidence: A)
• Choice of Initial Monotherapy vs Initial Combination Therapy
  • Initiation of Antihypertensive Therapy with 2 First-Line Agents of Different Classes, Either as Separate Agents or in a Fixed-Dose Combination, is Recommended in Adults with stage 2 hypertension and an average Blood Pressure >20/10 mm Hg Above Their Blood Pressure Target (Class of Recommendation: I, Level of Evidence: C-EO)
  • Initiation of Antihypertensive Therapy with a Single Antihypertensive is Reasonable in Adults with Stage 1 Hypertension and Blood Pressure Goal <130/80 mm Hg with Dosage Titration and Sequential Addition of Other Agents to Achieve the Blood Pressure Target (Class of Recommendation: IIa, Level of Evidence: C-EO)
• Follow-Up After Initiating Antihypertensive Therapy
  • Adults Initiating a New or Adjusted Drug Regimen for Hypertension Should Have a Follow-Up Evaluation of Adherence and Response to Treatment at Monthly Intervals Until Control is Achieved (Class of Recommendation: I, Level of Evidence: B-R)
• Monitoring Strategies to Improve Control in Patients on Drug Therapy for Hypertension
  • Follow-Up and Monitoring After Initiation of Drug Therapy for Hypertension Control Should Include Systematic Strategies to Help Improve Blood Pressure, Including Use of Home Blood Pressure Monitoring (HBPM), Team-Based Care, and Telehealth Strategies (Class of Recommendation: I, Level of Evidence: A)
• Treatment of Hypertension in the Setting of Stable Ischemic Heart Disease (see Coronary Artery Disease)
  • In Adults with Stable Ischemic Heart Disease and Hypertension, a Blood Pressure Target of <130/80 mm Hg is Recommended (Class of Recommendation: I, Level of Evidence: SBP: B-R, DBP: C-EO)
  • Adults with Stable Ischemic Heart Disease and hypertension (BP ≥130/80 mm Hg) Should Be Treated with Medications (i.e. GDMT β-Blockers, ACE Inhibitors, or ARB’s) for Compelling indications (eg, previous MI, Stable Angina) as First-Line Therapy, with the Addition of Other Medications (i.e. Dihydropyridine Calcium Channel Blockers, Thiazide Diuretics, and/or Mineralocorticoid Receptor Antagonists) as Required to Further Control Hypertension (Class of Recommendation: I, Level of Evidence: SBP: B-R, DBP: C-EO)
  • In Adults with Stable Ischemic Heart Disease with Angina and Persistent Uncontrolled Hypertension, the Addition of Dihydropyridine Calcium Channel Blockers to GDMT β-Blockers is Recommended (Class of Recommendation: I, Level of Evidence: B-NR)
  • In Adults Who Have Had an Myocardial Infarction/Acute Coronary Syndrome, it is Reasonable to Continue GDMT β-Blockers Beyond 3 yrs as Long-Term Therapy for Hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
  • β-Blockers and/or Calcium Channel Blockers Might Be Considered to Control Hypertension in Patients with Coronary Artery Disease (without HFrEF) Who Had an Myocardial Infarction >3 yrs Ago and Have Angina (Class of Recommendation: IIb, Level of Evidence: C-EO)
• Treatment of Hypertension in the Setting of Congestive Heart Failure (CHF) (see Congestive Heart Failure)
  • In Hypertensive Adults at Increased Risk of Heart Failure, the Optimal Blood Pressure Should Be <130/80 mm Hg (Class of Recommendation: I, Level of Evidence-Systolic: B-R, Level of Evidence-Diastolic: C-EO)
• Treatment of Hypertension in the Setting of Heart Failure with Reduced Ejection Fraction (HFrEF) (see Congestive Heart Failure)
  • Adults with Heart Failure with Reduced Ejection Fraction (HFrEF) and Hypertension Should Be Prescribed Guideline-Directed Medical Therapy (GDMT) Titrated to Attain a Blood Pressure <130/80 mm Hg (Class of Recommendation: I, Level of Evidence: C-EO)
  • Non-Dihydropyridine Calcium Channel Blockers are Not Recommended in the Treatment of Hypertension in Adults with Heart Failure with Reduced Ejection Fraction (HFrEF) (Class of Recommendation: III-No Benefit, Level of Evidence: B-R)
• Treatment of Hypertension in the Setting of Heart Failure with Preserved Ejection Fraction (HFpEF) (see Congestive Heart Failure)
  • In Adults with Heart Failure with Preserved Ejection Fraction (HFpEF) Who Present with Symptoms of Volume Overload, Diuretics Should Be Prescribed to Control Hypertension (Class of Recommendation: I, Level of Evidence: C-EO)
  • Adults with Heart Failure with Preserved Ejection Fraction (HFpEF) Who and Persistent Hypertension After Management of Volume Overload Should Be Prescribed ACE Inhibitors or ARB’s and β-Blockers Titrated to Attain Systolic Blood Pressure of <130 mm Hg (Class of Recommendation: I, Level of Evidence: C-LD)
• Treatment of Hypertension in the Setting of Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
  • Adults with Hypertension and Chronic Kidney Disease (CKD) Should Be Treated to a Blood Pressure Goal of <130/80 mm Hg (Class of Recommendation: I, Level of Evidence: SBP: B-R, DBP: C-EO)
  • In Adults with Hypertension and Chronic Kidney Disease (CKD) (≥Stage 3 or Stage 1/22 with Albuminuria [≥300 mg/Day, or ≥300 mg/g Albumin-to-Creatinine Ratio or the Equivalent in the First Morning Void), Treatment with an ACE Inhibitor is Reasonable to Slow Kidney Disease Progression (Class of Recommendation: IIa, Level of Evidence: B-R)
  • In Adults with Hypertension and Chronic Kidney Disease (CKD) (≥Stage 3 or Stage 1/2 with Albuminuria [≥300 mg/Day, or ≥300 mg/g Albumin-to-Creatinine Ratio in the First Morning Void), Treatment with an ARB May Be Reasonable if an ACE Inhibitor is Not Tolerated
• Treatment of Hypertension in the Setting of Renal Transplantation (see Renal Transplant)
  • After Kidney Transplantation, Treat Patients with Hypertension to a Blood Pressure Goal of <130/80 mm Hg (Class of Recommendation: IIa, Level of Evidence: SBP: B-NR, DBP: C-EO)
  • After Kidney Transplantation, Treat Patients with Hypertension with a Calcium Channel Blocker on the Basis of Improved Glomerular Filtration Rate (GFR) and Kidney Survival (Class of Recommendation: IIa, Level of Evidence: B-R)
• Treatment of Hypertension in the Setting of Acute Intracerebral Hemorrhage (see Intracerebral Hemorrhage)
  • In Adults with Intracerebral Hemorrhage Who Present with Systolic Blood Pressure (SBP) >220 mm Hg, Use Continuous Intravenous Antihypertensives (with Close Blood Pressure Monitoring to Decrease the Systolic Blood Pressure (SBP) (Class of Recommendation: IIa, Level of Evidence: C-EO)
  • In Adults with Spontaneous Intracerebral Hemorrhage Who Present within 6 hrs of the Acute Event and Have an Systolic Blood Pressure (SBP) Between 150-220 mm Hg, Immediately Decreasing the Systolic Blood Pressure (SBP) to <140 mm Hg Does Not Decrease the Mortality Rate/Risk of Severe Disability and Can Be Potentially Harmful (Class of Recommendation: III: Harm, Level of Evidence: A)
• Treatment of Hypertension in the Setting of Acute Ischemic Stroke (see Ischemic Cerebrovascular Accident)
  • Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Pressure Carefully Decreased to <185/110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I, Level of Evidence: B-NR)
  • In Adults with an Acute Ischemic Stroke, Blood Pressure Should Be <185/110 mm Hg Before Administration of Intravenous Thrombolytic Therapy and Should Be Maintained <180/105 mm Hg for ≥24 hrs After Initiation of Intravenous Thrombolytic Therapy Therapy (Class of Recommendation: I, Level of Evidence: B-NR)
  • Starting or Restarting Antihypertensive Therapy During Hospitalization in Patients with Blood Pressure >140/90 mm Hg Who are Neurologically Stable is Safe and Reasonable to Improve Long-Term Blood Pressure Control, Unless Contraindicated (Class of Recommendation: IIa, Level of Evidence: B-NR)
  • In Patients with Blood Pressure of ≥220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic Therapy or Mechanical Thrombectomy and Have No Comorbid Conditions Requiring Acute Antihypertensive Treatment, the Benefit of Initiating or Reinitiating Antihypertensive Therapy within the First 48-72 hrs is Uncertain (Class of Recommendation: IIb, Level of Evidence: C-EO)
    • It Might Be Reasonable to Decrease Blood Pressure by 15% During the First 24 hrs After the Onset of Stroke
  • In Patients with Blood Pressure <220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic Therapy or Mechanical Thrombectomy and Do Not Have a Comorbid Condition Requiring Acute Antihypertensive Treatment, Initiating or Reinitiating Antihypertensive Therapy within the Furst 48-72 hrs After an Acute Ischemic Stroke is Not Effective to Prevent Death or Dependency (Class of Recommendation: III: No Benefit, Level of Evidence: A)
  • Adults with Previously Treated Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) Should Be Restarted on Antihypertensive Treatment After the First Few Days of the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I: No Benefit, Level of Evidence: A)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Treatment with a Thiazide Diuretic, ACE Inhibitor, or ARB, or Combination Treatment Consisting of a Thiazide Diuretic Plus ACE Inhibitor, is Useful (Class of Recommendation: I: No Benefit, Level of Evidence: A)
  • Adults Not Previously Treated for Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) and Have an Established Blood Pressure ≥140/90 mm Hg Should Be Prescribed Antihypertensive Treatment a Few Days After the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I: No Benefit, Level of Evidence: B-R)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Selection of Specific Drugs Should Be Individualized on the Basis of Patient Comorbidities and Agent Pharmacological Class (Class of Recommendation: I: No Benefit, Level of Evidence: B-NR)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), a Blood Pressure Goal of <130/80 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit, Level of Evidence: B-R)
  • For Adults with a Lacunar Stroke, a Target Systolic Blood Pressure (SBP) Goal of <130 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit, Level of Evidence: B-R)
  • In Adults Previously Untreated for Hypertension Who Experience an Ischemic Stroke or Transient Ischemic Attack (TIA) and Have a Systolic Blood Pressure (SBP) <140 mm Hg and a Diastolic Blood Pressure (DBP) <90 mm Hg, the Usefulness of Initiating Antihypertensive Treatment is Not Well Established (Class of Recommendation: IIb: No Benefit, Level of Evidence: C-LD)
• Secondary Stroke Prevention
  • Adults with Previously Treated Hypertension WHo Experience a Stroke or Transient Ischemic Attack (TIA) Should Be Restarted on Antihypertensive Treatment After the First Few Days of the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I, Level of Evidence: A)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Treatment with a Thiazide Diuretic, ACE Inhibitor, or ARB, or Combination Treatment Consisting of a Thiazide Diuretic Plus ACE Inhibitor, is Useful (Class of Recommendation: I, Level of Evidence: A)
  • Adults Not Previously Treated for Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) and Have an Established Blood Pressure of ≥140/90 mm Hg Should Be Prescribed Antihypertensive Therapy a Few Days After the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I, Level of Evidence: B-R)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Selection of Specific Drugs Should Be Individualized on the Basis of Patient Comorbidities and Agent Pharmacological Class (Class of Recommendation: I, Level of Evidence: B-NR)
  • For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), a Blood Pressure Goal of <130/80 mm Hg May Be Reasonable (Class of Recommendation: IIb, Level of Evidence: B-R)
  • For Adults with a Lacunar Stroke, a Target Systolic Blood Pressure Goal of <130 mm Hg May Be Reasonable (Class of Recommendation: IIb, Level of Evidence: B-R)
  • In Adults Previously Untreated for Hypertension Who Experience an Ischemic Stroke or Transient Ischemic Attack (TIA) and Have a Systolic Blood Pressure <140 mm Hg and a Diastolic Blood Pressure <90 mm Hg, the Usefulness of Initiating Antihypertensive Treatment is Not Well Established (Class of Recommendation: IIb, Level of Evidence: C-LD)
• Treatment of Hypertension in the Setting of Peripheral Artery Disease (PAD) (see Peripheral Artery Disease)
  • Adults with Hypertension and Peripheral Artery Disease (PAD) Should Be Treated Similarly to Patients with Hypertension without Peripheral Artery Disease (PAD) (B-NR)
• Treatment of Hypertension in the Setting of Diabetes Mellitus (DM) (see Diabetes Mellitus)
  • In Adults with Diabetes Mellitus and Hypertension, Antihypertensive Treatment Should Be Initiated at a Blood Pressure ≥130/80 mm Hg with a Treatment Goal of <130/80 mm Hg (Class of Recommendation: I, Level of Evidence: SBG: B-R, DBP: C-EO)
  • In Adults with Diabetes Mellitus and Hypertension, All Firs-Line Classes of Antihypertensives (i.e. Diuretics, ACE Inhibitors, ARB’s, and Calcium Channel Blockers) are Useful and Effective (Class of Recommendation: I, Level of Evidence: A)
  • In Adults with Diabetes Mellitus and Hypertension, ACE Inhibitors or ARB’s May Be Considered in the Presence of Albuminuria (Class of Recommendation: IIb, Level of Evidence: B-NR)
• Treatment of Hypertension in the Setting of Atrial Fibrillation (see Atrial Fibrillation)
  • Treatment of Hypertension with an ARB Can Be Useful for the Prevention of Recurrence of Atrial Fibrillation (Class of Recommendation: IIa, Level of Evidence: B-R)
• Treatment of Hypertension in the Setting of Valvular Heart Disease
  • In Adults with Asymptomatic Aortic Stenosis, Hypertension Should Be Treated with Antihypertensives, Starting at a Low Dose and Gradually Titrating Upward (as Required) (Class of Recommendation: I, Level of Evidence: B-NR)
  • In Patients with Chronic Aortic Insufficiency, Treatment of Systolic Hypertension with Antihypertensives Which Do Not Slow the Heart Rate (i.e. Avoid β-Blockers) is Reasonable (Class of Recommendation: IIa, Level of Evidence: C-LD)
• Treatment of Hypertension in the Setting of Aortic Disease (see Thoracic Aortic Aneurysm)
  • β-Blockers are Recommended as the Preferred Antihypertensive in Patients with Hypertension and Thoracic Aortic Disease (Class of Recommendation: I, Level of Evidence: C-EO)
• Racial/Ethnic Differences in Hypertension Treatment
  • In Black Adults with Hypertension But without Congestive Heart Failure or Chronic Kidney Disease, Including those with Diabetes Mellitus, Initial Antihypertensives Should Include a Thiazide-Type Diuretic or Calcium Channel Blocker (Class of Recommendation: I, Level of Evidence: B-R)
  • Two or More Antihypertensives are Recommended to Achieve a Blood Pressure Target of <130/80 mm Hg in Most Adults with Hypertension, Especially in Black Adults with Hypertension (Class of Recommendation: I, Level of Evidence: C-LD)
• Treatment of Hypertension in the Setting of Pregnancy (see Pregnancy)
  • Women with Hypertension Who Become Pregnant, or are Planning to Become Pregnant, Should Be Transitioned to Methyldopa, Nifedipine, and/or Labetalol During Pregnancy (Class of Recommendation: I, Level of Evidence: C-LD)
  • Women with Hypertension Who Become Pregnant Should Not Be Treated with ACE Inhibitors, ARB’s, or Direct Renin Inhibitors (Class of Recommendation: III-Harm, Level of Evidence: C-LD)
• Age-Related Issues in Hypertension Treatment
  • Treatment of Hypertension with a Systolic Blood Pressure Treatment Goal of <130 mm Hg is Recommended for Noninstitutionalized Ambulatory Community-Dwelling Adults (≥65 y/o) with an Average Systolic Blood Pressure of ≥130 mm Hg (Class of Recommendation: I, Level of Evidence: A)
  • For Older Adults (≥65 y/o) with Hypertension and a High Burden of Comorbidity and Limited Life Expectancy, Clinical judgment, patient preference, and a team-based approach to assess Risk/Benefit is Reasonable for Decisions Regarding Intensity of Blood Pressure Lowering and Choice of Antihypertensives (Class of Recommendation: IIa, Level of Evidence: C-EO)
• Prevention of Cognitive Decline/Dementia (see Dementia)
  • In Adults with hypertension, Blood Pressure Lowering is Reasonable to Prevent Cognitive Decline and Dementia (Class of Recommendation: IIa, Level of Evidence: B-R)
• Treatment of Hypertension in the Setting of a Patient Undergoing a Surgical Procedure
  • Preoperative
    • In Patients with Hypertension Undergoing Major Surgery Who Have Been on β-Blockers Chronically, β-Blockers Should Be Continued (Class of Recommendation: I, Level of Evidence: B-NR)
    • In Patients with Hypertension undergoing Planned Elective Major Surgery, it is Reasonable to Continue Medical Therapy for Hypertension Until Surgery (Class of Recommendation: IIa, Level of Evidence: C-EO)
    • In Patients with Hypertension Undergoing Major Surgery, Discontinuation of ACE Inhibitors or ARB’s Perioperatively May Be Considered (Class of Recommendation: IIb, Level of Evidence: B-NR)
    • In Patients with Planned Elective Major Surgery and Systolic Blood Pressure of ≥180 mm Hg or Diastolic Blood Pressure of ≥110 mm Hg, Deferring Surgery May Be Considered (Class of Recommendation: IIb, Level of Evidence: C-LD)
    • For Patients Undergoing Surgery, Abrupt Preoperative Discontinuation of β-Blockers or Clonidine is Potentially Harmful (Class of Recommendation: III-Harm, Level of Evidence: B-NR)
    • β-Blockers Should Not Be Started on the Day of Surgery in β-Blocker Naive Patients (Class of Recommendation: III-Harm, Level of Evidence: B-NR)
  • Intraoperative
    • Patients with intraoperative Hypertension Should Be Managed with Intravenous medications (Table 19) Until Such Time as Oral Medications Can Be Resumed (Class of Recommendation: I, Level of Evidence: C-EO)
• Antihypertensive Medication Adherence Strategies
  • In Adults with Hypertension, Dosing of Antihypertensive Medication Once Daily Rather than Multiple Times Daily is Beneficial to Improve Adherence (Class of Recommendation: I, Level of Evidence: B-R)
  • Use of Combination Pills Rather than Free Individual Components Can Be Useful to Improve Adherence to Antihypertensives (Class of Recommendation: IIa, Level of Evidence: B-NR)
• Strategies to Promote Lifestyle Modification
  • Effective Behavioral and Motivational Strategies to Achieve a Healthy Lifestyle (i.e. Tobacco Cessation, Weight Loss, Moderation in Alcohol Intake, Increased Physical Activity, Reduced Sodium Intake, and Consumption of a Healthy Diet) are Recommended for Adults with Hypertension (Class of Recommendation: I, Level of Evidence: C-EO)
• Structured, Team-Based Care Interventions for Hypertension Control
  • A Team-Based Care Approach is Recommended for Adults with Hypertension (Class of Recommendation: I, Level of Evidence: A)
• Health Information Technology–Based Strategies to Promote Hypertension Control
  • Use of the Electronic Health Record and Patient Registries is Beneficial for Identification of Patients with Undiagnosed or Undertreated Hypertension (Class of Recommendation: I, Level of Evidence: B-NR)
  • Use of the Electronic Health Record and Patient Registries is Beneficial for Guiding Quality Improvement Efforts Designed to Improve Hypertension Control (Class of Recommendation: I, Level of Evidence: B-NR)
• Telehealth Interventions to Improve Hypertension Control
  • Telehealth Strategies Cane Be Useful Adjuncts to Interventions Shown to Decrease Blood Pressure for Adults with Hypertension (Class of Recommendation: IIa, Level of Evidence: A)
• Performance Measures
  • Use of Performance Measures in Combination with Other Quality Improvement Strategies at Patient, Provider, and System-Based Levels is Reasonable to Facilitate Optimal Hypertension Control (Class of Recommendation: IIa, Level of Evidence: B-NR)
• Quality Improvement Strategies
  • Use of Quality Improvement Strategies at the Health System, Provider, and Patient Levels to Improve Identification and Control of Hypertension Can Be Effective (Class of Recommendation: IIa, Level of Evidence: B-R)
  • Financial Incentives Paid to Providers Can Be Useful in Achieving Improvements in Treatment and Management of Patient Populations with Hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
  • Health System Financing Strategies (i.e. Insurance Coverage and Copayment Benefit Design) Can Be Useful in Facilitating Improved Medication Adherence and Blood Pressure Control in Patients with Hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
• Plan of Care for Hypertension
  • Every Adult with Hypertension Should Have a Clear, Detailed, and Current Evidence-Based Plan of Care Which Ensures the Achievement of Treatment and Self-Management Goals, Encourages Effective Management of Comorbid Conditions, Prompts Timely Follow-up with the Healthcare Team, and Adheres to Cardiovascular Disease Guideline-Directed Medical Therapy (Class of Recommendation: I, Level of Evidence: C-EO)

α-Adrenergic Receptor Antagonists (α-Blockers) (see α-Adrenergic Receptor Antagonists)

Pharmacology

• Vasodilation

Agents

• Doxazosin (Cardura, Carduran) (see Doxazosin)
• Prazosin (Minipress) (see Prazosin)
• Terazosin (Hytrin, Zayasel) (see Terazosin)

Aldosterone Antagonist Diuretics

Pharmacology

• Aldosterone Antagonist

Agents

• Eplerenone (Inspa, Espler) (see Eplerenone)
• Spironolactone (Aldactone) (see Spironolactone)

Angiotensin II Receptor Blockers (ARB’s) (see Angiotensin II Receptor Blockers)

Pharmacology

• Angiotensin II Receptor Antagonist

Agents

• Azilsartan (Edarbi) (see Azilsartan)
• Candesartan (Atacand) (see Candesartan
• Eprosartan (Teveten) (see Eprosartan)
• Fimasartan (Kanarb) (see Fimasartan)
• Irbesartan (Avapro, Aprovel, Karvea) (see Irbesartan)
• Losartan (Cozaar) (see Losartan)
• Olmesartan (Benicar, Olmecip) (see Olmesartan)
• Telmisartan (Micardis) (see Telmisartan)
• Valsartan (Diovan) (see Valsartan)

Angiotensin Converting Enzyme (ACE) Inhibitors (see Angiotensin Converting Enzyme Inhibitors)

Pharmacology

• Angiotensin Converting Enzyme (ACE) Inhibitor

Agents

• Benazepril (Lotensin) (see Benazepril)
• Captopril (Capoten) (see Captopril)
• Enalapril (Vasotec, Enalaprilat) (see Enalapril)
• Fosinopril (Monopril) (see Fosinopril)
• Lisinopril (Zestril) (see Lisinopril)
• Moexipril (Univasc) (see Moexipril)
• Perindopril (Coversyl, Coversum, Preterax, Aceon) (see Perindopril)
• Quinapril (Accupril) (see Quinapril)
• Ramipril (Altace) (see Ramipril)
• Trandolapril (Mavik) (see Trandolapril)

Clinical Efficacy

• Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
  • Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
  • Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
  • ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
    • This Effect Persisted Well Beyond the Trial Period

β-Adrenergic Receptor Antagonists (β-Blockers) (see β-Adrenergic Receptor Antagonists)

Pharmacology

• β-Adrenergic Receptor Antagonism

β-Adrenergic Receptor Antagonist Agents Used as Oral Antihypertensives

• Cardioselective (β1-Selective) β-Blockers
  • Acebutolol (Sectral, Prent) (see Acebutolol)
  • Atenolol (Tenormin) (see Atenolol)
  • Betaxolol (Betoptic, Lokren, Kerlone) (see Betaxolol)
  • Bisoprolol (Bisotab, Concor, Corbis and Zebeta) (see Bisoprolol)
  • Metoprolol (Lopressor) (see Metoprolol)
  • Nebivolol (Bystolic) (see Nebivolol)
• Non-Selective β-Blockers
  • Nadolol (Corgard, Anabet, Solgol, Corzide, Alti-Nadolol, Apo-Nadol, Novo-Nadolol) (see Nadolol)
  • Propanolol (Inderal) (see Propanolol)
• β-Blockers with Intrinsic Sympathomimetic Activity (β-Adrenergic Receptor Antagonism + Low Level β-Adrenergic Receptor Agonism)
  • Acebutolol (Sectral, Prent) (see Acebutolol)
  • Penbutolol (Levatol, Levatolol, Lobeta, Paginol, Hostabloc, Betapressin) (see Penbutolol)
  • Pindolol (Visken, Betapindol, Blockin L, Blocklin L, Calvisken, Cardilate, Decreten, Durapindol, Glauco-Visken, Pectobloc, Pinbetol, Prindolol, Pynastin)
• β-Blockers with α-Blocking Activity
  • Carvedilol (Coreg) (see Carvedilol)
  • Labetalol (Normodyne, Trandate) (see Labetalol)

Calcium Channel Blockers (see Calcium Channel Blockers)

Pharmacology

• Calcium Channel Antagonism

Calcium Channel Blocker Agents Used as Oral Antihypertensives

• Dihydropyridines
  • Amlodipine (Norvasc) (see Amlodipine)
  • Felodipine (Plendil) (see Felodipine)
  • Isradipine (DynaCirc, Prescal) (see Isradipine)
  • Nifedipine (Procardia) (see Nifedipine)
  • Nisoldipine (Sular) (see Nisoldipine)
• Non-Dihydropyridines
  • Diltiazem (Cardizem) (see Diltiazem)
  • Verapamil (Calan, Isoptin, Verelan, Verelan PM, Bosoptin, Covera-HS) (see Verapamil)

Clinical Efficacy

• Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
  • Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
  • Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
  • ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
    • This Effect Persisted Well Beyond the Trial Period

Central α-Agonists/Other Centrally-Acting Agents

Agents

• Guanfacine (Tenex, Intuniv) (see Guanfacine)
  • Pharmacology
    • Selective α2A-Adrenergic receptor Agonist
• Methyldopa (Aldomet) (see Methyldopa)
  • Pharmacology
    • Acts on α2-Adrenergic Receptors, Inhibits the Release of Norepinephrine from Presynaptic Neurons
• Clonidine (Catapres) (see Clonidine)
  • Pharmacology
    • α2A-Adrenergic Receptor Agonist
  • Administration
    • Oral (PO)
    • Topical (Patch)

Direct Vasodilators

Agents

• Hydralazine (Apresoline) (see Hydralazine)
  • Pharmacology
    • Arteriolar Direct-Acting Smooth Muscle Relaxant, Resulting in Vasodilation
  • Administration
    • Intravenous (IV)
    • Oral (PO)
• Minoxidil (Loniten) (see Minoxidil)
  • Pharmacology
    • Direct Vasodilator

Loop Diuretics

Pharmacology

• Loop Diuretic

Agents

• Bumetanide (Bumex) (see Bumetanide)
• Furosemide (Lasix) (see Furosemide)
• Torsemide (Demadex, Tortas, Wator) (see Torsemide)

Direct Renin Inhibitors

Pharmacology

• Renin Inhibitor

Agents

• Aliskiren (Tekturna, Rasilez) (see Aliskiren)

Omega 3 Fatty Acids (see Omega-3 Fatty Acid)

Pharmacology

• Omega 3 Fatty Acids

Clinical Efficacy

• Dose-Response Meta-Analysis of Omega-3 Fatty Acids in the Treatment of Hypertension (J Am Heart Assoc, 2022) [MEDLINE]
  • Optimal Combined Intake of Omega-3 Fatty Acids for Blood Pressure Lowering is Likely Between 2-3 g/Day
  • Doses of Omega-3 Fatty Acid Intake Above the Recommended 3 g/Day May Be Associated with Additional Benefits in Lowering Blood Pressure Among Groups at High Risk for Cardiovascular Diseases

Potassium-Sparing Diuretics

Pharmacology

• Potassium-Sparing Diuretics

Agents

• Amiloride (Midamor) (see Amiloride)
• Triamterene (Dyrenium) (see Triamterene)

Thiazide Diuretics/Thiazide-Like Diuretics

Pharmacology

• Thiazide/Thiazide-Like Diuretic

Agents

• Chlorthalidone (Hygroton, Thalitone) (see Chlorthalidone)
• Hydrochlorothiazide (Hydrodiuril) (see Hydrochlorothiazide)
• Indapamide (Lozol, Natrilix) (see Indapamide)
• Metolazone (Zytanix, Metoz, Zaroxolyn, and Mykrox) (see Metolazone)

Clinical Efficacy

• Secondary Analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to Study the Impact of Antihypertensives on Morbidity/Mortality (JAMA Netw Open, 2023) [MEDLINE]: randomized to thiazide-type diuretic (n = 15,002), a calcium channel blocker (n = 8,898), or an ACE inhibitor (n = 8,904) for planned in-trial follow-up of approximately 4-8 yrs and post-trial passive follow-up for up to 23 yrs
  • Cardiovascular Disease Mortality Rate was Similar Across All 3 Groups
  • Long-Term Risks of Most Secondary Outcomes (All-Cause Mortality, Combined Fatal and Nonfatal Morbidity for Cardiovascular Disease, Morbidity/Mortality for Coronary Artery Disease, Morbidity/Mortality Stroke, Morbidity/Mortality for Heart failure, Morbidity/Mortality for End-Stage Renal Disease, and Morbidity/Mortality for Cancer) were Similar Across All 3 Groups
  • ACE Inhibitors Increased the Risk of Stroke Outcomes by 11%, as Compared to Diuretics
    • This Effect Persisted Well Beyond the Trial Period

Clinical Efficacy

• Although There are No Randomized Trials Studying the Treatment of Asymptomatic Elevated Inpatient Blood Pressure, Observational Studies Suggest that Pharmacologic Blood Pressure Treatment May Carry Risks in This Setting
  • Study of Treatment of Inpatient Hypertension in Adults Hospitalized for Non-Cardiac Diagnoses (JAMA Intern Med, 2021) [MEDLINE]: n = 22, 834
    • In a Propensity-Matched Sample Controlling for Patient and Blood Pressure Characteristics, Treated Patients Had Higher Rates of Subsequent Acute Kidney Injury (10.3% vs 7.9%; P < 0.001) and Myocardial Injury (1.2% vs 0.6%; P = 0.003)
  • Retrospective Cohort Study of Use of PRN Intravenous Antihypertensives in Severe Inpatient Hypertension (J Clin Hypertens-Greenwich, 2022) [MEDLINE]: n = 22,000
    • Patients Treated with Intravenous Antihypertensives were 40% More Likely to Have a ≥30% Reduction in Mean Arterial Pressure
    • Intravenous Antihypertensive Treatment was Associated with a 60% Greater Risk of Myocardial Injury
  • VA Retrospective Cohort Study of Inpatient Blood Pressure Management in Patients >65 y/o Hospitalized for Non-Cardiac Diagnoses (JAMA Intern Med, 2023) [MEDLINE]: n = 66,140
    • Primary Outcome was a Composite of Inpatient Mortality, Intensive Care Unit Transfer, Stroke, Acute Kidney Injury, B-Natriuretic Peptide Elevation, and Troponin Elevation
    • Intensive Blood Pressure Treatment was Associated with an Increased Risk of the Primary Composite Outcome (8.7% vs 6.9%); Weighted Odds Ratio 1.28; 95% CI: 1.18-1.39)
      • Highest Risk was in Patients Who Received Intravenous Antihypertensives (Weighted Odds Ratio 1.90; 95% CI: 1.65-2.19)
    • Intensively-Treated Patients were More Likely to Experience Each Component of the Composite Outcome Except for Stroke and Mortality
    • Findings were Consistent Across Subgroups Stratified by Age, Frailty, Preadmission Blood Pressure, Early Hospitalization Blood Pressure, and History of Cardiovascular Disease
• It is important to consider that a patient’s BP may take several days to weeks to adjust to a medication change
  • Therefore, a typical inpatient stay is unlikely to be sufficient to fully assess the effect of a single medication change, and close outpatient follow-up is needed

Recommendations

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• For Adults without a Compelling Condition (Such as Aortic Dissection, Severe Preeclampsia/Eclampsia, Pheochromocytoma), Systolic Blood Pressure Should Be Decreased by ≤25% within the First 1 hr (Class of Recommendation: I: Harm, Level of Evidence: C-EO)
  • Then, if Stable, Blood Pressure Should Be Adjusted to 160/100 mm Hg within the next 2-6 hrs (Class of Recommendation: I: Harm, Level of Evidence: C-EO)
  • Then, Cautiously Adjust Blood Pressure to Normal During the Following 24-48 hrs (Class of Recommendation: I: Harm, Level of Evidence: C-EO)

General Comments

XXXXXXXXX

• There is No Proven Clinical Benefit to Rapidly Reduce Blood Pressure in the Setting of Hypertensive Urgency
• However, Hypertensive Emergency is Considered Life-Threatening and Requires Immediate Treatment

Emergency Department Interventions

• XXXXXXX
• Feasibility and short-term effects of a multi-component emergency department blood pressure intervention: a pilot randomized trial. J Am Heart Assoc. Published online February 23, 2022. doi:10.1161/JAHA.121.024339 [MEDLINE]

Intensive Care Unit (ICU) Admission for for Hypertensive Urgency/Emergency

• Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
  • In Adults with Hypertensive Emergency, Intensive Care Unit (ICU) Admission is Recommended for Continuous Blood Pressure Monitoring, Monitoring for Target Organ Damage, and Intravenous Antihypertensive Administration (Class of Recommendation: 1, Level of Evidence: B-NR)

Treatment of Hypertensive Emergency in the Setting of Hypertensive Encephalopathy (see Hypertensive Encephalopathy and Hypertensive Encephalopathy) (Hypertension, 2024) [MEDLINE]

Agents

• Labetalol (XXXXXXX) (see Labetalol)
• Nicardipine (XXXXXX) (see Nicardipine)

Goals

• Immediately Decrease the Mean Arterial Blood Pressure (MAP) by 20-25%

Treatment of Hypertensive Emergency in the Setting of Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident)

Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke (Stroke, 2013) [MEDLINE]

Blood Pressure Management in the Setting of Thrombolytic Therapy

• Antihypertensive Options in a Patient Otherwise Eligible for Acute Reperfusion Therapy, Except that Blood Pressure is >185/110 mm Hg
  • Labetalol 10–20 mg IV Over 1–2 min (May Repeat x 1) (see Labetalol)
  • Nicardipine 5 mg/h IV Infusion, Titrate Up by 2.5 mg/hr q5–15 min (Maximum: 15 mg/hr) (see Nicardipine)
    • When Desired Blood Pressure is Reached, Adjust to Maintain Proper Blood Pressure Limits
  • Hydralazine IV (see Hydralazine)
  • Enalaprilat IV (see Enalaprilat)
• If Blood Pressure is Not Maintained at ≤185/110 mm Hg, Do Not Administer Thrombolytic Therapy
• Management of Blood Pressure During and After Thrombolytic Therapy or Other Acute Reperfusion Therapy to Maintain Blood Pressure ≤180/105 mm Hg
  • Monitor Blood Pressure q15 min x 2 hrs from the Start of Thrombolytic Therapy, then q30 min x 6 hrs, and then q1hr x 16 hrs
  • Antihypertensive Options if Systolic Blood Pressure >180–230 mm Hg or Diastolic Blood Pressure >105–120 mm Hg
    • Labetalol 10 mg IV, Followed by Continuous IV Infusion 2–8 mg/min (see Labetalol)
    • Nicardipine 5 mg/h IV Infusion, Titrate Up to Desired Effect by 2.5 mg/hr q5–15 min (Maximum: 15 mg/hr) (see Nicardipine)
  • If Blood Pressure is Not Controlled or Diastolic Blood Pressure is >140 mm Hg, Consider Nitroprusside IV Infusion (see Nitroprusside)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Pressure Carefully Decreased to <185/110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I, Level of Evidence: B-NR)
• In Adults with an Acute Ischemic Stroke, Blood Pressure Should Be <185/110 mm Hg Before Administration of Intravenous Thrombolytic Therapy and Should Be Maintained <180/105 mm Hg for ≥24 hrs After Initiation of Intravenous Thrombolytic Therapy Therapy (Class of Recommendation: I, Level of Evidence: B-NR)
• Starting or Restarting Antihypertensive Therapy During Hospitalization in Patients with Blood Pressure >140/90 mm Hg Who are Neurologically Stable is Safe and Reasonable to Improve Long-Term Blood Pressure Control, Unless Contraindicated (Class of Recommendation: IIa, Level of Evidence: B-NR)
• In Patients with Blood Pressure of ≥220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic Therapy or Mechanical Thrombectomy and Have No Comorbid Conditions Requiring Acute Antihypertensive Treatment, the Benefit of Initiating or Reinitiating Antihypertensive Therapy within the First 48-72 hrs is Uncertain (Class of Recommendation: IIb, Level of Evidence: C-EO)
  • It Might Be Reasonable to Decrease Blood Pressure by 15% During the First 24 hrs After the Onset of Stroke
• In Patients with Blood Pressure <220/120 mm Hg Who Did Not Receive Intravenous Thrombolytic Therapy or Mechanical Thrombectomy and Do Not Have a Comorbid Condition Requiring Acute Antihypertensive Treatment, Initiating or Reinitiating Antihypertensive Therapy within the Furst 48-72 hrs After an Acute Ischemic Stroke is Not Effective to Prevent Death or Dependency (Class of Recommendation: III: No Benefit, Level of Evidence: A)
• Adults with Previously Treated Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) Should Be Restarted on Antihypertensive Treatment After the First Few Days of the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I: No Benefit, Level of Evidence: A)
• For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Treatment with a Thiazide Diuretic, ACE Inhibitor, or ARB, or Combination Treatment Consisting of a Thiazide Diuretic Plus ACE Inhibitor, is Useful (Class of Recommendation: I: No Benefit, Level of Evidence: A)
• Adults Not Previously Treated for Hypertension Who Experience a Stroke or Transient Ischemic Attack (TIA) and Have an Established Blood Pressure ≥140/90 mm Hg Should Be Prescribed Antihypertensive Treatment a Few Days After the Index Event to Decrease the Risk of Recurrent Stroke and Other Vascular Events (Class of Recommendation: I: No Benefit, Level of Evidence: B-R)
• For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), Selection of Specific Drugs Should Be Individualized on the Basis of Patient Comorbidities and Agent Pharmacological Class (Class of Recommendation: I: No Benefit, Level of Evidence: B-NR)
• For Adults Who Experience a Stroke or Transient Ischemic Attack (TIA), a Blood Pressure Goal of <130/80 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit, Level of Evidence: B-R)
• For Adults with a Lacunar Stroke, a Target Systolic Blood Pressure (SBP) Goal of <130 mm Hg May Be Reasonable (Class of Recommendation: IIb: No Benefit, Level of Evidence: B-R)
• In Adults Previously Untreated for Hypertension Who Experience an Ischemic Stroke or Transient Ischemic Attack (TIA) and Have a Systolic Blood Pressure (SBP) <140 mm Hg and a Diastolic Blood Pressure (DBP) <90 mm Hg, the Usefulness of Initiating Antihypertensive Treatment is Not Well Established (Class of Recommendation: IIb: No Benefit, Level of Evidence: C-LD)

Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke (Stroke, 2018) [MEDLINE]

• Hypotension/Hypovolemia Should Be Corrected to Maintain Systemic Perfusion (Class of Recommendation: I, Level of Evidence: C-EO)
  • The Blood Pressure Level Which Should Be Maintained in Patients with Acute Ischemic Stroke to Ensure the Best Outcome is Unknown
    • Some Observational Studies Demonstrate an Association Between Worse Outcome and Lower Blood Pressure, Whereas Other Studies Have Not
    • No Studies Have Addressed the Treatment of Low Blood Pressure in Patients with Acute Ischemic Stroke
  • Type of Intravenous Fluid
    • In a Systematic Analysis of 12 Studies Comparing Colloids with Crystalloids, the Odds of Death/Dependency were Similar (Clinically Important Benefirs/Harms Could Not Be Excluded)
    • No Studies Have Compared Different Isotonic Intravenous Fluids
  • Volume/Duration of Intravenous Fluid
    • No Data to Guide Volume/Duration of Intravenous Fluid Delivery
• Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Carefully Lowered to <185/110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I, Level of Evidence: B-NR)
  • The Randomized Controlled Trials of Intravenous Alteplase Required the Systolic Blood Pressure to Be <185 mm Hg and Diastolic Blood Pressure to Be <110 mm Hg Before Treatment and <180/105 mm Hg for the First 24 hrs After Treatment
    • Some Observational Studies Suggest that the Risk of Hemorrhage After Administration of Thrombolytics is Greater in Patients with Higher Blood Pressure and in Patients with More Blood Pressure Variability
    • The Exact Blood Pressure at which the Risk of Hemorrhage After Thrombolysis Increases is Unknown
    • Therefore, it is Reasonable to Target the Blood Pressures Used in the Randomized Controlled Trials of Intravenous Thrombolytics
• The Usefulness of Drug-Induced Hypertension in the Setting of Acute Ischemic Stroke is Not Well Established (Class of Recommendation: IIb, Level of Evidence: C-LD)

Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2019 Guidelines for the Early Management of Patients With Acute Ischemic Stroke (Stroke, 2019) [MEDLINE]

Management of Hypotension/Hypovolemia (see Hypotension and Hypovolemic Shock)

• Hypotension/Hypovolemia Should Be Corrected to Maintain Systemic Perfusion Levels Necessary to Support Organ Function (Class of Recommendation: I, Level of Evidence: C-EO)
  • The Optimal Blood Pressure Level Which Should Be Maintained in Patients with Acute Ischemic Stroke is Unknown
    • Some Observational Studies Demonstrate an Association Between Worse Outcomes and Lower Blood Pressures, Whereas Other Studies Do Not
    • No Studies Address the Treatment of Hypotension in Patients with Stroke
  • Type of Intravenous Fluid
    • In a Systematic Analysis of 12 Studies Comparing Colloids with Crystalloids, the Odds of Death or Dependence were Similar (and Clinically Important Benefits or Harms Could Not Be Excluded)
    • No Studies Have Compared Different Isotonic Intravenous Fluids
  • Volume/Duration of Intravenous Fluid
    • No Data to Guide Volume/Duration of Intravenous Fluid Delivery

General Blood Pressure Management

• In Patients with Acute Ischemic Stroke, Early Antihypertensive Treatment is Indicated When Required by the Presence of Comorbid Conditions (Such as Concomitant Acute Coronary Syndrome, Acute Congestive Heart Failure, Aortic Dissection, Hypertensive Encephalopathy, Post-Fibrinolysis Intracerebral Hemorrhage, Preeclampsia/Eclampsia) (Class of Recommendation: I, Level of Evidence: C-EO)
  • Patients with Acute Ischemic Stroke Can Present with Severe Acute Comorbidities Which Demand Emergency Blood Pressure Reduction to Prevent Serious Complications
    • However, Since Excessive Blood Pressure Reduction Can Exacerbate Cerebral Ischemia, Management Should Be Individualized
    • Initial Blood Pressure Reduction by 15% is a Reasonable Goal
    • There is No Data to Demonstrate Efficacy of One Blood Pressure Control Strategy Over Another After Acute Ischemic Stroke
• The Usefulness of Drug-Induced Hypertension in the Setting of Acute Ischemic Stroke is Not Well Established (Class of Recommendation: IIb, Level of Evidence: B-NR)

Blood Pressure Management in the Setting of Thrombolytic Therapy

• Patients Who Have Elevated Blood Pressure and are Otherwise Eligible for Treatment with Thrombolytic Therapy Should Have Their Blood Pressure Carefully Decreased so that Their Systolic Blood Pressure is <185 mm Hg and Their Diastolic Blood Pressure is <110 mm Hg Before Thrombolytic Therapy is Initiated (Class of Recommendation: I, Level of Evidence: B-NR)
  • The Randomized Controlled Trials of Intravenous Alteplase Required Systolic <185 mm Hg and Diastolic Blood Pressure <110 mm Hg Before Thrombolytic Therapy and <180/105 mm Hg for the First 24 hrs After Thrombolytic Therapy
  • Some Observational Studies Suggest that the Risk of Hemorrhage After Administration of Alteplase is Greater in Patients with Higher Blood Pressures and in Patients with More Blood Pressure Variability
    • The Exact Blood Pressure at Which the Risk of Hemorrhage After Thrombolytics Increases is Unknown
    • Therefore, it is Reasonable to Target the Blood Pressures Used in the Randomized Controlled Trials of Intravenous Alteplase

Blood Pressure Management in the Setting of Mechanical Thrombectomy

• In Patients for Whom Mechanical Thrombectomy is Planned and Who Have Not Received Thrombolytic Therapy, it is Reasonable to Maintain Blood Pressure ≤185/110 mm Hg Before the Procedure (Class of Recommendation: IIa, Level of Evidence: B-NR)
  • Of the 6 Randomized Controlled trials Which Each Independently Demonstrated Clinical Benefit of Mechanical Thrombectomy with Stent Retrievers when Performed <6 hrs from Stroke Onset, the REVASCAT/SWIFT PRIME/EXTEND-IA/THRACE/MR CLEAN Trials Had Eligibility Exclusions for Blood Pressure >185/110 mm Hg, While the ESCAPE Trial Had No Blood Pressure Eligibility Exclusions
    • The DAWN Trial Also Used an Exclusion for Blood Pressure >185/110 mm Hg
    • Randomized Controlled trial Data for Optimal Blood Pressure Management Approaches in this Setting are Not Available
    • Because the Vast Majority of Patients Enrolled in these Randomized Controlled Trials Had Preprocedural Blood Pressure Managed <185/110 mm Hg, it is Reasonable to Use This Level as a Guideline Until Additional Data Become Available
• In Patients Who Undergo Mechanical Thrombectomy with Successful Reperfusion, it is Reasonable to Maintain Blood Pressure at <180/105 mm Hg (Class of Recommendation: IIb, Level of Evidence: B-NR)
• In Patients Who Undergo Mechanical Thrombectomy, it is Reasonable to Maintain the Blood Pressure at ≤180/105 mm Hg During and for 24 hrs After the Procedure (Class of Recommendation: IIa, Level of Evidence: B-NR)

Blood Pressure Management in the Absence of Thrombolytic Therapy

• In Patients with BP ≥220/120 mm Hg Who Did Not Receive Reperfusion Therapy (Thrombolytic Therapy, Mechanical Thrombectomy) and Have No Comorbid Conditions Requiring Urgent Antihypertensive Treatment, the Benefit of Initiating/Reinitiating Antihypertensive Treatment within the First 48-72 hrs is Uncertain (Class of Recommendation: IIb, Level of Evidence: C-EO)
  • It is Reasonable to Lower Blood Pressure by 15% During the First 24 hrs After Onset of Acute Ischemic Stroke
  • Patients with Severe Hypertension (Most Commonly >220/120 mm Hg) were Excluded from Clinical Trials Evaluating Blood Pressure Reduction After Acute Ischemic Stroke
    • Rapid Blood Pressure Reduction Has Traditionally Been Advised for These Cases, But the Benefit of Such Treatment in the Absence of Comorbid Conditions Which May Be Acutely Exacerbated by Severe Hypertension Has Not Been Formally Studied
  • Ideal Management in These Situations Should Be Individualized, But an Initial Blood Pressure Reduction by 15% is a Reasonable Goal
  • Excessive Decrease in Blood Pressure Could Result in Complications, Such as Stroke Progression (by Compromising Cerebral Perfusion in Penumbral Tissue) and Acute Kidney Injury (from Renal Hypoperfusion)
  • There is No Data to Demonstrate Efficacy of One Blood Pressure Control Strategy Over Another After Acute Ischemic Stroke
• In Patients with Blood Pressure <220/120 mm Hg Who Did Not Receive Reperfusion Therapy (Thrombolytic Therapy, Mechanical Thrombectomy) and Do Not Have a Comorbid Condition Requiring Urgent Antihypertensive Therapy (Aortic Dissection, Severe HELLP Syndrome/Preeclampsia/Eclampsia, Pheochromocytoma, etc), Initiating/Reinitiating Antihypertensive Treatment within the First 48-72 hrs After an Acute Ischemic Stroke is Not Effective to Prevent Death or Dependency (Class of Recommendation: III-No Benefit, Level of Evidence: A)
  • Multiple Randomized Controlled Trials and Meta-Analyses of These Trials Have Consistently Demonstrated that Initiating/Reinitiating Antihypertensive Treatment within the first 48-72 hrs After an Acute Ischemic Stroke is Safe, But This Strategy is Not Associated with Improved Mortality or Functional Outcomes
    • However, None of These Trials were Designed to Study Blood Pressure Reduction within the First 6 hrs After Stroke, and All Excluded Patients with Extreme Hypertension or Coexistent Indications for Rapid Blood Pressure Reduction

Treatment of Hypertensive Emergency in the Setting of Intracerebral Hemorrhage (ICH) (see Intracerebral Hemorrhage)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• In Adults with Intracerebral Hemorrhage Who Present with Systolic Blood Pressure (SBP) >220 mm Hg, Use Continuous Intravenous Antihypertensives (with Close Blood Pressure Monitoring to Decrease the Systolic Blood Pressure (SBP) (Class of Recommendation: IIa, Level of Evidence: C-EO)
• In Adults with Spontaneous Intracerebral Hemorrhage Who Present within 6 hrs of the Acute Event and Have an Systolic Blood Pressure (SBP) Between 150-220 mm Hg, Immediately Decreasing the Systolic Blood Pressure (SBP) to <140 mm Hg Does Not Decrease the Mortality Rate/Risk of Severe Disability and Can Be Potentially Harmful (Class of Recommendation: III: Harm, Level of Evidence: A)

Recommendations-American Heart Association (AHA)/American Stroke Association (ASA) 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage (Stroke, 2022) [MEDLINE]

• In Patients with Spontaneous Intracerebral Hemorrhage Requiring Acute Antihypertensive Therapy, Careful Titration to Ensure Continuous Smooth and Sustained Blood Pressure Control (Avoiding Peaks and Large Variability in Systolic Blood Pressure), Can Improve Functional Outcome (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In Patients with Spontaneous Intracerebral Hemorrhage in Whom Acute Blood Pressure Lowering is Considered, Initiating Treatment within 2 hrs of Intracerebral Hemorrhage Onset and Reaching the Blood Pressure Target within 1 hrs Can Decrease the Risk of Hematoma Expansion and Improve Functional Outcome (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Patients with Spontaneous Mild-Moderate Intracerebral Hemorrhage Presenting with Systolic Blood Pressure between 150-220 mm Hg, Acute Decrease in the Systolic Blood Pressure to a Target of 140 mm Hg with the Goal of Maintaining Systolic Blood Pressure in the Range of 130-150 mm Hg is Safe and May Be Reasonable for Improving Functional Outcomes (Class of Recommendation: 2b, Level of Evidence: B-R)
• In Patients with Spontaneous Large-Severe Intracerebral Hemorrhage or Those Requiring Surgical Decompression, the Safety and Efficacy of Intensive Blood Pressure Decrease are Not Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Patients with Spontaneous Mild-Moderate Intracerebral Hemorrhage Presenting with SBP >150 mm Hg, Acute Decrease in Systolic Blood Pressure to <130 mm Hg is Potentially Harmful (Class of Recommendation: 3-Harm, Level of Evidence: B-R)

Treatment of Hypertensive Emergency in the Setting of Aortic Dissection (see Aortic Dissection)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• For Adults with a Compelling Condition (Aortic Dissection, Severe Preeclampsia/Eclampsia, Pheochromocytoma), Systolic Blood Pressure Should Be Decreased to <140 mm Hg During the First 1 hr and to <120 mm Hg in Aortic Dissection (Class of Recommendation: I, Level of Evidence: C-EO)
  • Aortic Dissection Requires Rapid Lowering of Systolic Blood Pressure to <120 mm Hg (within Approximately 20 min)
  • β-Blockade Should Precede any Required Vasodilator (Nicardipine, Nitroprusside) Administration to Prevent Reflex Tachycardia or Increased Inotropy

Treatment of Hypertensive Emergency in the Setting of Hemolysis Elevated Liver Functions Low Platelets (HELLP) Syndrome/Preeclampsia/Eclampsia (see Aortic Dissection)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• For Adults with a Compelling Condition (Aortic Dissection, Severe Preeclampsia/Eclampsia, Pheochromocytoma), Systolic Blood Pressure Should Be Decreased to <140 mm Hg During the First 1 hr and to <120 mm Hg in Aortic Dissection (Class of Recommendation: I, Level of Evidence: C-EO)

Treatment of Hypertensive Emergency in the Setting of Congestive Heart Failure (CHF) (see Congestive Heart Failure)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• In Hypertensive Adults at Increased Risk of Heart Failure, the Optimal Blood Pressure Should Be <130/80 mm Hg (Class of Recommendation: I, Level of Evidence-Systolic: B-R, Level of Evidence-Diastolic: C-EO)
• Adults with Heart Faillure with Reduced Ejection Fraction (HFrEF) and Hypertension Should Be Prescribed Guideline-Directed Medical Therapy (GDMT) Titrated to Attain a Blood Pressure <130/80 mm Hg (Class of Recommendation: I, Level of Evidence: C-EO)
• Non-Dihydropyridine Calcium Channel Blockers are Not Recommended in the Treatment of Hypertension in Adults with Heart Faillure with Reduced Ejection Fraction (HFrEF) (Class of Recommendation: III-No Benefit, Level of Evidence: B-R)
• In Adults with Heart Failure with Preserved Ejection Fraction (HFpEF) Who Present with Symptoms of Volume Overload, Diuretics Should Be Prescribed to Control Hypertension (Class of Recommendation: I, Level of Evidence: C-EO)
• Adults with Heart Failure with Preserved Ejection Fraction (HFpEF) Who and Persistent Hypertension After Management of Volume Overload Should Be Prescribed ACE Inhibitors or ARB’s and β-Blockers Titrated to Attain Systolic Blood Pressure of <130 mm Hg (Class of Recommendation: I, Level of Evidence: C-LD)

Recommendations-2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure (Circulation, 2022) [MEDLINE]

Assessment of Patients Hospitalized With Decompensated Heart Failure

• In Patient Hospitalized with Heart Failure, Severity of Congestion and Adequacy of Perfusion Should Be Assessed to Guide Triage and Initial Therapy (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Patient Hospitalized with Heart Failure, the Common Precipitating Factors and the Overall Patient Trajectory Should Be Assessed to Guide Appropriate Therapy (Class of Recommendation: 1, Level of Evidence: C-LD)
• For Patient Admitted with Heart Failure, Treatment Should Address Reversible Factors, Establish Optimal Volume Status, and Advance Guideline-Directed Medical Therapy (GDMT) Toward Targets for Outpatient Therapy (Class of Recommendation: 1, Level of Evidence: C-LD)

Maintenance or Optimization of Guideline-Directed Medical Therapy (GDMT) During Hospitalization

• In Patients with HFrEF Requiring Hospitalization, Preexisting Guideline-Directed Medical Therapy (GDMT) Should Be Continued and Optimized to Improve Outcome, Unless Contraindicated (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Patients Experiencing a Mild Decrease in Renal Function or Asymptomatic Reduction of Blood Pressure During Heart Failure Hospitalization, Diuresis and Other Guideline-Directed Medical Therapy (GDMT) Should Not Routinely Be Discontinued (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Patients with HFrEF, Goal-Directed Medical Therapy (GDMT) Should Be Initiated During Hospitalization After Clinical Stability is Achieved (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Patients with HFrEF, if Discontinuation of Guideline-Directed Medical Therapy (GDMT) is Necessary During Hospitalization, it Should Be Reinitiated and Further Optimized as Soon as Possible (Class of Recommendation: 1, Level of Evidence: B-NR)

Use of Diuretics

• Patients with Heart Failure Admitted with Significant Fluid Overload Should Be Treated with Intravenous Loop Diuretics to Improve Symptoms and Decrease Morbidity (Class of Recommendation: 1, Level of Evidence: B-NR)
• For Patients Hospitalized with Heart Failure, Therapy with Diuretics and Other Guideline-Directed Medications Should Be Titrated with a Goal to Resolve Clinical Evidence of Congestion to Decrease Symptoms and Rehospitalizations (Class of Recommendation: 1, Level of Evidence: B-NR)
• For Patients Requiring Diuretic Treatment During Hospitalization for Heart Failure, the Discharge Regimen Should Include a Plan for Adjustment of Diuretics to Decrease Rehospitalizations (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Patient Hospitalized with Heart Failure When Diuresis is Inadequate to Relieve Symptoms/Signs of Congestion, Intensify the Diuretic Regimen Using Either Higher Doses of Intravenous Loop Diuretics or Addition of a Second Diuretic (Class of Recommendation: 2a, Level of Evidence: B-NR)

Use of Vasodilators

• In Patient Admitted with Decompensated Heart Failure, in the Absence of Systemic Hypotension, Intravenous Nitroglycerin or Nitroprusside May be Considered as an Adjuvant to Diuretic Therapy for Relief of Dyspnea (Class of Recommendation: 2b, Level of Evidence: B-NR)

Treatment of Hypertensive Emergency in the Setting of Acute Coronary Syndrome (ACS) (see Coronary Artery Disease)

Recommendations-American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Hypertension (ASH) Guideline on Treatment of Hypertension in Those with Coronary Artery Disease (Heart Lung Circ, 2015) [MEDLINE]

• Recommended Blood Pressure Target is 140/90
  • Blood Pressure <130/80 is Recommended at Time of Hospital Discharge

Treatment of Hypertensive Emergency in the Setting of Pheochromocytoma (see Pheochromocytoma)

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

• For Adults with a Compelling Condition (Aortic Dissection, Severe Preeclampsia/Eclampsia, Pheochromocytoma), Systolic Blood Pressure Should Be Decreased to <140 mm Hg During the First 1 hr and to <120 mm Hg in Aortic Dissection (Class of Recommendation: I, Level of Evidence: C-EO)

Treatment of Hypertensive Emergency in the Setting of Carotid Endarterectomy (CEA) (see Carotid Endarterectomy)

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Treatment of Hypertensive Emergency in the Setting of Cocaine Intoxication (see Cocaine)

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Treatment of Hypertensive Emergency in the Setting of Perioperative Hypertension

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Antihypertensive Agents for Hypertensive Emergencies (Hypertension, 2018) [MEDLINE]

Clevidipine (Cleviprex) (see Clevidipine)

• Pharmacology
  • Dihydropyridine Calcium Channel Blocker (see Calcium Channel Blockers)
• Contraindications
  • Soybean/Soy/Egg Allergy
  • Defective Lipid Metabolism (i.e. Pathological Hyperlipidemia, Lipoid Nephrosis, or Acute Pancreatitis)
• Continuous Intravenous Administration
  • Initial 1–2 mg/hr Intravenous Infusion
    • Double q90 sec Until Blood Pressure Approaches Target, then Increase by Less than Double q5–10 min (as Required)
    • Maximum Dose: 32 mg/hr
    • Maximum Duration: 72 hrs
  • Use Low-End Dose Range for Elderly Patients

Enalaprilat (Vasotec) (see Enalapril)

• Pharmacology
  • Angiotensin Converting Enzyme (ACE) Inhibitor (see Angiotensin Converting Enzyme Inhibitors)
    • Mainly Useful in Hypertensive Emergencies Associated with High Plasma Renin Activity
    • Relatively Slow Onset of Action: 15 min
    • Unpredictable Antihypertensive Response
• Contraindications
  • Acute Myocardial Infarction (MI) (see Coronary Artery Disease)
  • Bilateral Renal Artery Stenosis (see Renal Artery Stenosis)
  • Pregnancy (see Pregnancy)
• Intermittent Intravenous Administration
  • Initial 1.25 mg Intravenous Push (Over 5 min)
    • Increase Dose Up to 5 mg q6 hrs (as Required)

Esmolol (Brevibloc) (see Esmolol)

• Pharmacology
  • β1-Adrenergic Receptor Antagonist (see β-Adrenergic Receptor Antagonists)
• Contraindications
  • 2°/3° Heart Block (see Second Degree Atrioventricular Block-Mobitz Type II and Third Degree Atrioventricular Block)
  • Bradycardia (see Sinus Bradycardia)
  • Moderate-Severe Left Ventricular Dysfunction (see Congestive Heart Failure)
  • Reactive Airway Disease (Asthma/Chronic Obstructive Pulmonary Disease/COPD) (see Asthma and Chronic Obstructive Pulmonary Disease)
• Intravenous Loading Dose and Continuous Intravenous Administration
  • Intravenous Loading Dose: 500–1000 μg/kg/min
  • Continuous Intravenous Infusion: 50 μg/kg/min
    • For Additional Dosing: bolus dose is repeated and the infusion increased in 50 μg/kg/min increments (maximum: 200 μg/kg/min) (as required)

Fenoldopam Mesylate (Corlopam) (see Fenoldopam)

• Pharmacology
  • Dopamine D1-Receptor Selective Agonist
• Contraindications
  • Increased Intraocular Pressure (Glaucoma)
  • Increased Intracranial Pressure
  • Sulfite Allergy
• Adverse Effects
  • Reflex Tachycardia (see Sinus Tachycardia)
• Continuous Intravenous Infusion
  • Initial 0.1–0.3 μg/kg/min Intravenous Infusion
    • Increase Infusion in Increments of 0.05–0.1 μg/kg/min q15 min (Maximum: 1.6 μg/kg/min) (as Required)

Hydralazine (Apresoline) (see Hydralazine)

• Pharmacology
  • Direct Vasodilator
    • Onset: within 10-30 min
    • Duration: 2-4 hrs
    • Unpredictable Antihypertensive Response
• Intermittent Intravenous Administration
  • Initial 10 mg Slow Intravenous Push (Maximum Initial Dose: 20 mg)
    • Repeat 10-20 mg q4-6 hrs (as Required)

Labetalol (see Labetalol)

• Pharmacology
  • Combined α1-Blocker and Nonselective β-Blocker (see α1-Adrenergic Receptor Antagonists and β-Adrenergic Receptor Antagonists)
    • Labetalol has an α/β Antagonism Ratio of 1:7 (Br Heart J, 1977) [MEDLINE]
• Contraindications
  • 2°/3° Heart Block (see Second Degree Atrioventricular Block-Mobitz Type II and Third Degree Atrioventricular Block)
  • Bradycardia (see Sinus Bradycardia)
  • Moderate-Severe Left Ventricular Dysfunction (see Congestive Heart Failure)
  • Reactive Airway Disease (Asthma/Chronic Obstructive Pulmonary Disease/COPD) (see Asthma and Chronic Obstructive Pulmonary Disease)
• Onset: 5-10 min
• Duration: 3-6 hrs
• Intermittent Intravenous Administration
  • Administer 10-20 mg Slow Intravenous Push q10 min
• Continuous Intravenous Infusion
  • Initial 0.5-3.5 mg/min (Note: Some Patients Require Up to 10 mg/min) (Chest, 2007) [MEDLINE] (Curr Opin Crit Care, 2011) [MEDLINE] (Expert Opin Investig Drugs, 2012) [MEDLINE] (Hypertension, 2018) [MEDLINE] (NEJM, 2019) [MEDLINE]
  • Maximum Cumulative Dose: 300 mg (which can be repeated q4-6 hrs)

Nicardipine (Cardene) (see Nicardipine)

• Pharmacology
  • Dihydropyridine Calcium Channel Blocker (see Calcium Channel Blockers)
• Contraindications
  • Advanced Aortic Stenosis (see Aortic Stenosis)
• Continuous Intravenous Infusion
  • Initial 5 mg/hr
    • Increase q5 min by 2.5 mg/hr (Maximum: 15 mg/hr) (as Required)
  • No Dose Adjustment Required for Elderly Patient

Nitroglycerin (see Nitroglycerin)

• Pharmacology
  • Nitric Oxide-Dependent Vasodilator
• Contraindications
  • Hypovolemia
  • Right Ventricular Infarction
• Continuous Intravenous Infusion
  • Initial 5 μg/min Intravenous Infusion
    • Increase Infusion in Increments of 5 μg/min q3–5 min (Maximum: 20 μg/min) (as Required)

Nitroprusside (Nipride) (see Nitroprusside)

• Pharmacology
  • Nitric Oxide-Dependent Vasodilator
    • Onset of Action: immediate
    • Duration of Action: 1-2 min
• Cautions
  • Arterial Line Monitoring of Blood Pressure is Recommended
  • Cyanide Toxicity Can Occur with Prolonged Nitroprusside Use (Resulting in Irreversible Neurological Changes and Cardiac Arrest)
    • Use Shortest Duration of Treatment as Possible
    • For Infusion Rates ≥4–10 μg/kg/min or Duration >30 min, Thiosulfate Can Be Coadministered to Prevent Cyanide Toxicity
  • Tachyphylaxis is Common with Extended Duration of Use
• Continuous Intravenous Administration
  • Initial 0.3–0.5 μg/kg/min Intravenous Infusion
    • Increase Infusion in Increments of 0.5 μg/kg/min (Maximum: 10 μg/kg/min) (as Required)
  • Use Low-End Dosing for Elderly Patient

Phentolamine (Regitine) (see Phentolamine)

• Pharmacology
  • Nonselective α-Blocker
    • Particularly Useful for Hypertensive Emergencies Induced by Excess Catecholamine (Pheochromocytoma, Interactions Between Monamine Oxidase Inhibitors and Other Drugs or Food, Cocaine Intoxication, Amphetamine Intoxication, or Clonidine Withdrawal
• Intermittent Intravenous Administration
  • Initial 5 mg Intravenous Push
    • Repeat 5 mg Doses q10 min (as Required)

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