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7 Intravenous Anti-Hypertensives for Hypertensive Crisis - #MEDSHED

Updated: Aug 10, 2023

Depending on indication and patient parameters, you may have to reach deep into the drug bank. Here are seven intravenous antihypertensives -

 

7 intravenous antihypertensives for hypertensive emergencies


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)

  1. 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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