- 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.