Summary
Hypertensive crises are a group of clinicopathological entities in which rapid reduction of hypertension is necessary to prevent serious end-organ damage. The diagnosis and treatment plan depends on the identification of specific end-organ dysfunction. The goal of treatment is to limit the progression of end-organ damage in patients with hypertensive crises. Several potent antihypertensive drugs, such as sodium nitroprusside, labetalol and urapidil, are available to produce an immediate fall in blood pressure. The choice of the drug should be made on the basis of its pharmacodynamic properties, clinical effects, advantages and contraindications. Additionally, rapid reduction of blood pressure carries a considerable risk, if it is performed in an uncontrolled manner, leading to further end-organ damage. The aim of the treatment is not just to reduce blood pressure, but to do so with minimal adverse effects while preserving organ function.
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References
The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 1993; 153: 154–83.
Kaplan NM. Management of hypertensive emergencies. Lancet 1994; 344: 1335–8.
Shepherd AMM, Irvine NA. Differential hemodynamic and sympathoadrenal effects of sodium nitroprusside and hydralazine in hypertensive subjects. J Cardiovasc Pharmacol 1986; 8: 527–33.
Gifford RW. Management of hypertensive crises. JAMA 1991; 266: 829–35.
Prisant LM, Carr AA, Hawkins DW. Treating hypertensive emergencies: controlled reduction of blood pressure and protection of target organs. Postgrad Med 1993; 93: 92–6.
Gross G, Hanft G, Kolassa N. Urapidil and some analogues with hypotensive properties show high affinities for 5-hydroxy-tryptamine (5-HT) binding sites of the 5-HT1A subtype and for alpha 1-adrenoceptor binding sites. Naunyn Schmiedebergs Arch Pharmacol 1987; 336: 597–601.
Späh F, Grosser KD, Thieme G. Acute hemodynamic effects of urapidil and nifedipine in hypertensive urgencies and emergencies. Drugs 1990; 40 Suppl. 4: 58–9.
Wang RYC, Chow JSF, Chan KH, et al. Acute hemodynamic and myocardial metabolic effects of intravenous urapidil in severe heart failure. Eur Heart J 1984; 5: 745–51.
Schook CE, Radtke H, Wurst W, et al. Overview of clinical trials with urapidil. Am J Cardiol 1989; 64: 30D–7D.
Hirschl MM, Seidler D, Zeiner A, et al. Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive urgencies. Am J Emerg Med 1993; 11: 653–6.
Farmer JB, Kennedy I, Levy GP, et al. Pharmacology of AH5158; a drug which blocks alpha and beta adrenoceptors. Br J Pharmacol 1972; 45: 660–75.
Dunn FG, Oigman W, Messerli FH, et al. Hemodynamic effects of intravenous labetalol in essential hypertension. Clin Pharmacol Ther 1983; 33: 139–43.
Cressman MD, Vidt DG, Gifford RW, et al. Intravenous labetalol in the management of severe hypertension and hypertensive emergencies. Am Heart J 1984; 107: 980–5.
Garrett BN, Kaplan NM. Efficacy of slow infusion of diazoxide in the treatment of severe hypertension without organ hypoperfusion. Am Heart J 1982; 103: 390–4.
Huysmans FTM, Thien TA, Koene RAP. Combined intravenous administration of diazoxide and beta-blocking agent in acute treatment of severe hypertension or hypertensive crisis. Am Heart J 1982; 103: 395–400.
Kuzniar J, Skret A, Piela A, et al. Hemodynamic effects of intravenous hydralazine in pregnant women with severe hypertension. Obstet Gynecol 1985; 66: 453–8.
Remuzzi G, Ruggenenti P. Prevention and treatment of pregnancy associated hypertension: what have we learned in the last 10 years? Am J Kidney Dis 1991; 18: 285–305.
Vidt DG. Current concepts in treatment of hypertensive emergencies. Am Heart J 1986; 111: 220–5.
DiPette DJ, Ferraro JC, Evans RR, et al. Enalaprilat, an intravenous angiotensin-converting enzyme inhibitor in hypertensive crises. Clin Pharmacol Ther 1985; 38: 199–204.
Hirschl MM, Binder M, Bur A, et al. Clinical evaluation of different dosages of intravenous enalaprilat in patients with hypertensive crises. Arch Intern Med. In press.
Strauss R, Gavras I, Vlahakos D, et al. Enalaprilat in hypertensive emergencies. Clin Pharmacol 1986; 26: 39–43.
Wallin JD, Fletcher E, Ram CV, et al. Intravenous nicardipine for the treatment of severe hypertension: a double-blind, placebo-controlled multicenter trial. Arch Intern Med 1989; 149: 2262–9.
Bussmann WD, Kenedi P, Von Mengden HJ, et al. Comparison of nitroglycerin with nifedipine in patients with hypertensive crises or severe hypertension. Clin Investig 1992; 70: 1085–8.
Cottrell JE, Turndorf H. Intravenous nitroglycerin. Am Heart J 1978; 96: 550–3.
Dale RC, Schroeder ET. Respiratory paralysis during treatment of hypertension with trimetapham camsylate. Arch Intern Med 1976; 136: 816–8.
Kürkcyan I, Sterz F, Roden M, et al. A new preparation of nifedipine for sublingual application in hypertensive urgencies. Angiology 1994; 45: 629–35.
Frishman WH, Weinberg P, Peled HB, et al. Calcium entry blockers for the treatment of severe hypertension and hypertensive crisis. Am J Med 1984; 77: 35–45.
Rohr G, Reimnitz P, Blanke P. Treatment of hypertensive emergency: comparison of a new dosage form of the calcium antagonist nitrendipine with nifedipine capsules. Intensive Care Med 1994; 20: 268–71.
Healton EB, Brust JC, Feinfeld DA, et al. Hypertensive encephalopathy and the neurologic manifestations of malignant hypertension. Neurology 1982; 32: 127–32.
Dinsdale HB. Hypertensive encephalopathy. Stroke 1982; 13: 717–9.
Davalos A, Cendra E, Teruel J, et al. Deteriorating ischemie stroke: risk factors and prognosis. Neurology 1990; 40: 1865–9.
Barry DI. Cerebrovascular aspects of antihypertensive treatment. Am J Cardiol 1989; 63: 14C–18C.
Phillips SJ. Pathophysiology and management of hypertension in acute ischemie stroke. Hypertension 1994; 23: 131–6.
Graham DI. Ischaemic brain damage following emergency blood pressure lowering in hypertensive patients. Acta Med Scand 1983; Suppl. 678: 61–9.
Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care: Part IV. Special resuscitation situations: stroke. JAMA 1992; 268: 2242–4.
Wallace JD, Levy LL. Blood pressure after stroke. JAMA 1981; 246: 2177–80.
Braunwald E. Pathophysiology of heart failure. In: Braunwald E, editor. Heart disease. Philadelphia: Saunders, 1992: 393–418.
Lawrence E. Left ventricular failure and aortic dissection. In: Swales JE, editor. Textbook of hypertension. Oxford: Blackwell Scientific Publications, 1994: 1248–59.
Gibson TC. Blood pressure levels in acute myocardial infarction. Am Heart J 1987; 96: 475–9.
o’Mailia J, Sander G, Giles T. Nifedipine associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med 1987; 107: 185–7.
Renard M, Riviere A, Jacops P, et al. Treatment of hypertension in acute stage of myocardial infarction. Br Heart J 1983; 49: 522–7.
Prokop EK, Palmer RF, Wheat MW. Hemodynamic forces in dissecting aneurysms. Circ Res 1970; 27: 121–7.
DeSanctis RW, Doroghazi RM, Austen WG, et al. Aortic dissection. N Engl J Med 1987; 317: 1060–6.
St John Sutton MG, Sheps SG, Lie JT. Prevalence of clinically unsuspected pheochromocytoma: review of a 50-year autopsy series. Mayo Clin Proc 1981; 56: 354–60.
Hauptman JB, Modlinger RS, Ertel NH. Pheochromocytoma resistant to alpha adrenergic blockade. Arch Intern Med 1983; 143: 2321–5.
Navaratnarajah M, White DC. Labetalol and pheochromocytoma. Br J Anaesth 1984; 56: 1179.
Alpert M, Bauer J. Hypertensive emergencies: recognition and pathogenesis. Cardiovasc Rev Rep 1985; 6: 407–11.
Lindheimer MD, Katz AI. Hypertension in pregnancy. N Engl J Med 1985; 313: 675–80.
Gales MA. Oral antihypertensives for hypertensive urgencies. Ann Pharmacother 1994; 28: 352–8.
Angeli P, Chiesa M, Caregaro L, et al. Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies. A randomized, single-blind clinical trial. Arch Intern Med 1991; 151: 678–82.
Jaker M, Atkins S, Soto M, et al. Oral nifedipine vs oral clonidine in the treatment of urgent hypertension. Arch Intern Med 1989; 149: 260–65.
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Hirschl, M.M. Guidelines for the Drug Treatment of Hypertensive Crises. Drugs 50, 991–1000 (1995). https://doi.org/10.2165/00003495-199550060-00007
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DOI: https://doi.org/10.2165/00003495-199550060-00007