Depending on indication and patient parameters, you may have to reach deep into the drug bank. Here are seven intravenous antihypertensives -
Hypertensive crisis is severe hypertension that results in end organ damage and life-threatening complications. Hypertensive emergencies need to have blood pressure controlled within a target goal. Overshooting results in hypoperfusion and worse outcomes. Depending on the indication and patient parameters, you may have to reach deep into the drug bank. Here are seven intravenous antihypertensives for the next time you need rapid blood pressure control.
Mechanism of action
Nonselective beta blocker
IV push + continuous infusion
Preference
Neuro-hypertensive emergency (AIS, ICH, PRES)
Acute Coronary Syndromes
Pre-eclampsia/Eclampsia
Pharmacokinetics
Onset: < 5 minutes
Duration: 4 - 18 hours (dose dependent)
T1/2= ~5.5 hours
Contraindicated
Bronchial asthma, overt cardiac failure, greater-than-first degree heart block, cardiogenic shock, severe bradycardia, other conditions associated with severe and prolonged hypotension
Insight
Great kinetics and the preferred IV push in most cases. Excellent tool to bridge to continuous infusions. Lowers HR and BP. With continued use, you'll have a general sense of how IV push labetolol fits in your practice in relation to other accessible antihypertensives (formulary, ADM proximity, etc).
Mechanism of action
Direct vasodilator
IV push
Pharmacokinetics
Onset: within 5 or delayed up to 80 min
Duration: up to 12 hours
T1/2: ~ 5 hours
Preference
Pre-eclampsia/Eclampsia
Contraindicated:
Hypersensitivity to hydralazine
Coronary artery disease
Mitral valvular rheumatic heart disease
Caution
Unpredictable kinetics
Systemic lupus erythematosus including glomerulonephritis
Insight
We have to work with what we've got. It does come handy at times for bradycardic patients, but I often find myself using nicardipine/clevidipine or NitroPaste. The unpredictable kinetics gets you in trouble stacking additive vasodilatory effects.
Mechanism of action:
Angiotensin converting-enzyme inhibitor
IV push
Preference
Limited use in true hypertensive crisis
Acute hypertension when enteral administration is inappropriate
Pharmacokinetics
Onset: within 15 minutes
Duration: 4 hours
T1/2: 11 hours
Contraindicated
Hypersensitivities; History of angioedema related to previous treatment with an angiotensin converting enzyme inhibitor, and in patients with hereditary or idiopathic angioedema
Caution
Angioedema
Excessive hypotension
Prolonged duration
Slower onset
Insight
I personally have not seen such much use with the patient populations I've worked with. Does come with limitations (slow onset, longer duration) and I haven't come across a patient it made sense yet.
Mechanism of action
Dihydropyradine calcium channel blocker
Continuous IV infusion
Preferred
Neuro-hypertensive emergency (AIS, ICH, PRES)
Acute Coronary Syndromes
Contraindications
Advanced aortic stenosis
Caution: Hepatic impairment/congestive heart failure. Avoid small veins.
Insight
It gets the job done. Rapid onset, short offset. Clevidipine is just more rapid with a quicker offset. More physicians are familiar with historically used nicardipine. Do no harm; I am in favor of utilizing what the team is most comfortable with. That means be familiar with both nicardipine/clevidipine.
Mechanism of action
Dihydropyradine calcium channel blocker; continuous IV infusion (3rd generation, quicker onset/offset compared to nicardipine)
Preferred
Neuro-hypertensive emergency (AIS, ICH, PRES)
Acute Coronary Syndromes
Pharmacokinetics
Onset: < 2 mins
Duration: < 10 mins
T1/2: ~2 minutes
Contraindicated
Hypersensitivities; allergy to soy; severe aortic stenosis, lipid metabolism disorder
Caution
Reflex tachycardia
Heart failure
Insight
Clevidipine can be used in different etiologies for hypertensive crisis. The medication is new and physicians/nurses/pharmacists are less familiar with titration recommendations. Although, it is an effective antihypertensive once you become familiar with the kinetics and active bedside titration. Great for afterload reduction. Compatible with emergent continuous infusions. It has become my bread and butter.
Mechanism of action
Direct vasodilator via conversion of nitric oxide (NO)
Dilatation of the veins promotes peripheral pooling of blood and decreases venous return to the heart, thereby reducing left ventricular end-diastolic pressure and pulmonary capillary wedge pressure (preload)
Arteriolar relaxation reduces systemic vascular resistance, systolic arterial pressure, and mean arterial pressure (afterload)
Preferred
STEMI
Sympathetic Crashing Acute Pulmonary Edema (SCAPE)
Pharmacokinetics
Onset: Within 5 minutes
Duration: 4 hours
T1/2= 3 minutes
Contraindication
Pericardial tamponade, restrictive cardiomyopathy, or constrictive pericarditis, cardiac output is dependent upon venous return
Allergy to corn or corn products
Medications for erectile dysfunction and riociguat.
Caution: Tachyphylaxis, pericardial tamponade, restrictive cardiomyopathy
Insight: Nitroglycerin provides venodilation at lower and arteridilation with higher rates. Be mindful of what the indication is; MI vs SCAPE? Crank that NTG drip up greater than AT LEAST 100 mcg/min. Great for MI.
Mechanism of action
Direct vasdilator via oxyhemoglobin to produce methemoglobin, cyanide, and nitric oxide (NO)
Preferred
SCAPE
ADHF
Pharmacokinetics
Onset: < 2 mins
Duration: 10 mins
T1/2: ~ 2 mins
Contraindicated
Disease with compensatory hypertension
Inadequate cerebral circulation or moribund patients
Congeital optial atrophy or tobacco amblyopia
Acute heart failure with reduced peripheral vascular resistance
Concomitant use with sildeanfil, tadalafil, vardenafil, or riociguat
Caution
Thiocynate toxicity
Methemoglobinemia
Increases ICP
Insight
Clevidipine is more readily available in the ED for SCAPE and acute aortic syndromes. There are concerns with it's use, but under ICU care, nitroprosside is awesome in HF patients.
The Right Drug for the Right Conditions
There is no one-size-fits-all approach when it comes to managing hypertensive emergencies. Each patient and clinical presentation have their unique challenges. With more options, you can select the best agent for the patient. Seven IV antihypertensives to keep in mind; labetolol, hydralazine, enaleprelat, nitroglycerin, sodium nitroprussire, clevidipine, nicardipine. Don't be the reason the patient crumps either by under- or overshooting.
Mark Nguyen, PharmD, BCEMP
References (package insert linked to drug name listed above)
Ipek et al. Hypertensive crisis: an update on clinical approach and management. Curr Opin Cardiol. 2017 Jul;32(4):397-406. doi: 10.1097/HCO.0000000000000398.
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