michigan hypertension core curriculum - State of Michigan

trials included a placebo arm. Seven drug classes were identified: nitrates (9 trials), ACE inhibitors (7
trials), Calcium channel blockers (6 trials), alpha-1- adrenergic antagonists (4 trials), diuretics (3 trials),
direct vasodilators (2 trials) and dopamine agonists (1 trial). Table 3 lists the drugs primarily used for
the management of hypertensive emergencies. Hypertensive emergencies are treated initially with
intravenous medications while hypertensive urgencies are almost always treated with oral medications.
Table 3—Dosage of Commonly Used Parenteral Antihypertensive Medications
Clevidipine 2 mg/hour, titrate as needed by doubling every 3 minutes to maximum dose 32 mg/hour 13a
Enalaprilat 1.25 mg over 5 min every 4 to 6 h, titrate by 1.25-mg
increments at 12- to 24-h intervals to maximum of 5 mg q6h
Esmolol 500 μg/kg loading dose over 1 min, infusion at 25 to 50 μg/
kg/min, increased by 25 μg/kg/min every 10 to 20 min to maximum of 300 μ/kg/min
Fenoldopam 0.1 μg/kg/min initial dose, 0.05 to 0.1 μg/kg/min increments
to maximum of 1.6 μg/kg/min
Labetalol 20-mg initial bolus, 20- to 80-mg repeat boluses or start
infusion at 2 mg/min with maximum 24-h dose of 300 mg
Nicardipine 5 mg/h, increase at 2.5 mg/h increments every 5 min to
maximum of 15 mg/h
Nitroglycerin 5 μg/min, titrated by 5 μg/min every 5 to 10 min to
maximum of 60μg/min
Nitroprusside 0.5 μg/kg/min, increase to maximum of 2 μg/kg/min to
avoid toxicity
Phentolamine 1- to 5-mg boluses, maximum 15-mg dose
General treatment principles in this setting have been established – immediate lowering of
BP to levels that halt additional hypertensive TOD without inducing new TOD due to ischemia. JNC-
7 6 suggests that BP be lowered no more than 25% within the first hour, and then to 160/100-110
within 2-6 hours. An alternative and more cautious set of BP goals would be to lower BP ~ 10% in
the first few hours and then by no more than 25% during the first 24 hours. As detailed below, other
recommendations exist for particular situations. The need for immediate but controlled decreases in
BP usually indicates the need for monitoring in a critical care setting with an arterial BP monitor, and
continuously infused intravenous medications.
240 Hypertension Core Curriculum