Management of Hypertensive Emergencies

General Principles

The American Heart Association recommends that all hypertensive emergencies (BP >180/120 mmHg with acute end-organ damage) require immediate ICU admission with continuous IV antihypertensive therapy, not oral agents 1, 2, 3
The American College of Cardiology suggests reducing SBP by maximum 25% within first hour for patients without compelling conditions (aortic dissection, severe preeclampsia/eclampsia, pheochromocytoma) 1, 2, 3
The American Heart Association recommends targeting 160/100 mmHg over next 2-6 hours if stable for patients without compelling conditions 1, 2, 3

For patients with aortic dissection, the American College of Cardiology recommends reducing SBP to <120 mmHg within 20 minutes 2, 4, 5
For patients with severe preeclampsia/eclampsia or pheochromocytoma, the American Heart Association recommends reducing SBP to <140 mmHg within first hour 1, 2

In acute aortic dissection, the American College of Cardiology recommends esmolol IV as a first-line agent, with a loading dose of 500-1000 mcg/kg over 1 minute and maintenance infusion of 50 mcg/kg/min 3, 5
In acute pulmonary edema, the American Heart Association recommends nitroglycerin IV as a first-line agent, with a starting dose of 5 mcg/min and titration every 3-5 minutes 3, 5
In acute coronary syndrome, the American College of Cardiology recommends nitroglycerin IV and esmolol IV as first-line agents, with a starting dose of 5 mcg/min and 50 mcg/kg/min, respectively 3, 4, 5

The American Heart Association recommends using sodium nitroprusside with caution due to the risk of cyanide toxicity and increased intracranial pressure, and monitoring for signs of toxicity such as irreversible neurological changes and cardiac arrest 1, 4, 5
The American College of Cardiology suggests using clevidipine IV with caution in patients with soybean, soy product, egg, or egg product allergy, and defective lipid metabolism 2, 3, 5
The American Heart Association recommends monitoring all patients with hypertensive emergencies in the ICU, with continuous BP monitoring, cardiac monitoring, and frequent assessment of target organ function 1, 2, 5