Aortic dissection | Reduce shear forces by ↓ BP and PR; lower SBP to 100–120 mm Hg35,36,37; or lower SBP to <140 mm Hg23; ↓ PR <60 beats/min | | | Measure BP in both arms and treat higher BP |
| | Labetalol35,36,37 IV continuous infusion or esmolol35,36,37 IV bolus, then continuous infusion | Respiratory distress in COPD, asthma patients; test dose of esmolol recommended, switch to diltiazem if esmolol intolerant36 | |
| | Nicardipine38 IV continuous infusion (after β-blocker) | | Always use β-blocker prior to vasodilators |
| | Nitroprusside36,37 continuous infusion (after β-blocker) | | Always use β-blocker prior to vasodilators; nitroprusside alone increases wall stress from reflex tachycardia; cyanide and thiocyanate toxicity in patients with reduced renal function or therapy >24–48 h |
Acute hypertensive pulmonary edema | Reduce BP by 20%–30%; diuresis through vasodilation; symptomatic relief | | | |
| | Nitroglycerin SL, topical, or IV continuous infusion39,40 | | IV nitrates dilate capacitance vessels at low doses; higher doses dilate arterioles and lower BP |
| | Enalaprilat IV40 | ACE inhibitor, can worsen renal function | Avoid hypotension |
| | Nicardipine IV continuous infusion | | Use with caution; some patients experience a negative inotropic effect |
| | Nitroprusside IV continuous infusion39,40 | | Cyanide and thiocyanate toxicity in patients with reduced renal function or therapy >24–48 h |
| | Nesiritide IV39,40 | Mixed outcomes (favorable and unfavorable) with nesiritide, with most recent ASCEND-HF trial showing no difference in dyspnea and mortality when compared to placebo41 | Nesiritide lowers PCWP more than nitroglycerin39 |
Acute myocardial infarction | Reduce ischemia; avoid ≤25% reduction of MAP42 | | BP >180/110 mm Hg is a relative contraindication for thrombolytics43,44 | |
| | Nitroglycerin SL, topical, or IV continuous infusion42,43,44 | Do not give nitrates in patients who have taken phosphodiesterase inhibitors for erectile dysfunction ≤24 h (48 h for tadalafil)43 | |
| | Metoprolol or labetalol IV bolus42,43,44 | Do not give β-blockers in CHF, low-output states, or other contraindications to β-blockers | Monitor for hypotension; consider RV infarct and volume depletion |
Acute sympathetic crisis (cocaine, amphetamines, MAOI toxicity) | Reduce excessive sympathetic drive and symptomatic relief | | | Labetalol is controversial; if given, administer along with a nitrate42 |
| | Benzodiazepine32,45 IV bolus | | Benzodiazepines are first-line agents; observe for respiratory depression |
| | Nitroglycerin SL, topical, or IV continuous infusion42,45 | | |
| | Phentolamine45 IV or IM | | |
| | Nicardipine IV continuous infusion42,45 | | |
Acute renal failure | Reduce BP by no more than 20% acutely11 | | | Do not give nitroprusside, as it results in cyanide and thiocyanate toxicity; avoid ACE inhibitor acutely (some authors contradict this caution)11 |
| | Nicardipine46 IV continuous infusion | | |
| | Clevidipine IV continuous infusion | | |
| | Fenoldopam46 IV continuous infusion | | |
Hypertensive encephalopathy | Decrease MAP 20%–25% in the first hour of presentation47; more aggressive lowering may lead to ischemic infarction | | | Autoregulation of cerebral perfusion may be significantly impaired, so avoid rapid BP lowering; do not give nitroglycerin48 as it may worsen cerebral autoregulation |
| | Nicardipine49 IV continuous infusion | | |
| | Labetalol50 IV continuous infusion | | Avoid in sympathetic crisis from drugs |
| | Fenoldopam50 IV continuous infusion | | |
| | Clevidipine IV continuous infusion51 | | |
Subarachnoid hemorrhage | SBP <160 mm Hg to prevent rebleeding52; avoid hypotension to preserve cerebral perfusion; BP parameters have not yet been defined52 | | | Nimodipine is used to decrease mortality. BP control is not its primary goal, but some decrease in BP may be seen.52 Clazosentan is used with success in lieu of nimodipine and has similar hypotensive effects.53 |
| | Nicardipine54,55,56 IV continuous infusion | | |
| | Labetalol52,56 IV bolus, 10–20 milligrams IV, or continuous infusion | | |
| | Esmolol IV bolus, then continuous infusion | | |
| | Clevidipine52 IV continuous infusion | | |
Intracerebral hemorrhage | If SBP >200 or MAP >150 mm Hg, consider aggressive management, IV infusion.57 If SBP >180 or MAP >130 mm Hg and possibly elevated ICP*, use infusions or IV boluses while maintaining CPP ≥60 mm Hg.57 If SBP >180 or MAP >130 mm Hg and no elevated ICP, goal MAP is 110 mm Hg (160/90 mm Hg).57 | | | Drops in SBP <150 mm Hg are not associated with increased morbidity.58 Early hemorrhage growth often occurs in first 6 h. Recent data suggest that during this time, aggressive BP control (SBP 120–160 mm Hg) diminishes hematoma growth, morbidity, and mortality.58,59,60 |
| | Labetalol56,61 IV bolus or continuous infusion | | |
| | Nicardipine56,61,62,63 IV continuous infusion | | |
| | Esmolol64 IV bolus, then continuous infusion | | |
Acute ischemic stroke, rtPA candidate (BP ≤185/110 mm Hg) | If fibrinolytic therapy planned, treat if BP remains >185/110 mm Hg after 3 measurements65; SBP goal is between 141 and 150 mm Hg66 | | Excess BP Lowering may worsen ischemia | Elevated BP spontaneously decreases within 90 min after onset of acute stroke symptoms |
| | Labetalol65 10–20 milligrams IV bolus; may repeat one time | | |
| | Nicardipine65 IV continuous infusion 5 milligrams/h, titrate up by 2.5 milligrams/h every 5–15 min; maximum 15 milligrams/h; adjust when desired BP is reached | | |
| | Nitroprusside65 may be used if BP is not controlled with above agents or DBP >140 mm Hg | | |
Acute ischemic stroke, hypertension excludes rtPA (BP >185/110 mm Hg) | Treat if >220/120 mm Hg on third of 3 measurements, spaced 15 min apart65 | | | Do not lower SBP by >10%–15% in first 24 h.65 BP that is lower during the acute ischemic stroke than the premorbid pressure could be considered hypotension. Be careful with BP control efforts in patients taking oral β-blockers or clonidine; antihypertensive withdrawal syndrome may occur. |
| | Labetalol65 10 milligrams IV bolus, followed by IV continuous infusion 2–8 milligrams/min | | |
| | Nicardipine65 5 milligrams/h IV continuous infusion, titrate up to desired effect by 2.5 milligrams/h every 5–15 min; maximum 15 milligrams/h | | |