- Hypertensive urgency: SBP > 180mmHg/DBP > 120mmHg
- Hypertensive emergency: SBP > 180mmHg/DBP > 120mmHg + end organ damage
- Are there signs/symptoms of end organ damage?
- Neurologic symptoms: agitation, delirium, stupor, seizures, visual disturbances
- Focal neurologic deficits
- Chest pain
- Back pain (consider aortic dissection)
- Dyspnea (consider pulmonary edema)
- BMP, LFTs, Troponin, BNP: Lab findings suggestive of end-organ damage
- Goal is to lower BP back to normal over 24-48 hours
- Initial lowering should be 10-20% in minutes if HTN emergency; goal should be 10-20% in 2-4 hours if HTN urgency
- Typically aim for initial goal BP near 160/110
- Exceptions to gradual lowering include:
- Acute stroke: call code stroke, lower ONLY if BP > 185/110 in pts under consideration for reperfusion therapy; or BP > 220/120 in pts not candidates for reperfusion therapy
- Aortic dissection: Goal = rapidly lower BP in minutes to target of 100-120 systolic to avoid aortic shearing forces
- Pharmacologic therapy
- If pt was previously on anti-HTN meds, ensure their home medicines have been restarted at appropriate doses, formulation (long acting vs. short), and dosing intervals
- If pt has a rapid acting anti-HTN med, can consider giving a dose early or an “extra dose” and then up titrating their overall daily dose
- Rescue therapies
- Captopril PO (12.5mg or 25mg dosed Q8H; conversion ratio of captopril:lisinopril = 5:1)
- Hydralazine PO (10-20mg initial dosing Q6H)
- Isosorbide dinitrate PO (5-20mg TID)
- Nifedipine XL PO (dose at 30mg initially, max 90 mg BID; NOT sublingual)
- Labetalol IV (10-40mg initially; dosed up to every 20-30mins)
- Hydralazine IV (10-20mg initially; dosed up to every 30 mins).
- Nitropaste 1” (can add/wipe away for titration; dose Q6H until oral meds can be started for better long-acting control)
- Dialysis if missed session
Refractory HTN: try additional agents listed above vs. escalation of care for drip (nicardipine, nitroglycerin, nitroprusside, esmolol).
Most drips that can be done for this indication are done in stepdown and usually require no-titration of the infusion and occasionally the MD to be bedside to initiate the infusion.
This includes diltiazem, labetalol, nitroglycerin, and verapamil drips. Nicardipine, esmolol, and nitroprusside drips are not allowed on step down.