Treatment of Asymptomatic Elevated Inpatient Blood Pressure
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)
Treatment of Hypertensive Emergency
General Comments
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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
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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)
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
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]
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]
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)
Prognosis
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One Year Mortality Rate XXXX
References
Treatment
Pharmacological basis for antihypertensive effects of intravenous labetalol. Br Heart J. 1977;39(1):99 [MEDLINE]
Hypertensive crises: challenges and management. Chest. 2007;131(6);1949-1962. doi: 10.1378/chest.06-2490 [MEDLINE]
Pharmacological management of hypertensive emergencies and urgencies: focus on newer agents. Expert Opin Investig Drugs. 2012;21(8):1089-1106. doi: 10.1517/13543784.2012.693477 [MEDLINE]
Diagnostic and therapeutic approach to the hypertensive crisis. Med Clin (Barc). 2018 Apr 23;150(8):317-322. doi: 10.1016/j.medcli.2017.09.027 [MEDLINE]
Initial Treatment of Hypertension. N Engl J Med. 2018 Feb 15;378(7):636-644. doi: 10.1056/NEJMcp1613481 [MEDLINE]
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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun;71(6):e13-e115. doi: 10.1161/HYP.0000000000000065 [MEDLINE]
ESC Council on hypertension position document on the management of hypertensive emergencies. European Heart Journal – Cardiovascular Pharmacotherapy (2019) 5, 37–46 doi:10.1093/ehjcvp/pvy032 [MEDLINE]
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