Hypertension Rx


Terminology sBP dBP  
Normal < 120 < 80  
Pre-hypertension 120-139 80-89  
Hypertension stage 1 140-159 90-99  
Hypertension stage 2 ≥ 160 ≥ 100  
Hypertensive Crisis
(malignant Hypertension)
≥ 180 ≥ 110 NO
end-organ injury
Hypertensive Emergency ≥ 180 ≥ 110 PLUS
End-organ damage

 
Drip
  1. Cardene Drip - Parenteral CCB, good initial choice, 5 mg/hour, titrate q 3 minutes, max 15 mg/hour.
    DO NOT USE P.O. Cardene (it's useless).
    • ↓ cerebral vasospasm, and therefore is a good for stroke syndromes.
       
  2. Nitroglycerine Drip - Good for cardiac hypertensive states, 10-20 mcg/min, increase 10-20 q 3min until desired effect max 100-200
 
IV
  1. ACEI
    • Enalaprilat (Vasotec IV) 0.625 - 1.25 mg IV q6h; (MAX: 5mg IV q6h)
    • Enalapril (Vasotec PO) 2.5, 5, 10, 20 mg IV q6h (MAX: 5mg IV q6h),
  2. Beta-blockers:
    • labetalol 10-20mg IVP, then 40-80 mg IV q10min prn; infusion: 1-8 mg/min; Max 300mg IV.
    • Metoprolol 5 mg q 15 min x 3;
  3. Nipride - 0.5 to 10 mcg/kg/min, releases CN, monitor thiocyanate levels.
  4. Hydralazine 10-20mg IV q30min.
  5. Nitroprusside 0.5 - 4 mcg/kg/min; MAX: 10 mcg/kg/min x 10 min.
    • Cerebral vasodilator, should be used carefully in stroke syndromes
  6. Diltiazem 20 mg → 5-15 mg/hr
 
PO
  1. Clonidine 0.2 mg x 1 then 0.1 mg q1h x 6;
    • 0.1 - 0.3 mg po TID, may incr. by 0.1 mg/day qwk; max: 2.4 mg/day.
      Taper dose over 2-4 days to D/C.
  2. Captopril 25 mg q1h x 4
  3. Minoxidil 10-40 mg PO qd or q12h (Max: 100mg qd, Half-life: 4.5 hr)
  4. Labetalol 200-400 mg q2-3h; or
  5. Nifedipine XL 30 mg x 1
 
Paste
  1. Nitro paste: Nitro-Bid 2% oint 0.5-2 inch topical q4-6h

 

Drug Effects:
Drug BP Pulse Comments
Labetolol α1-, β-Adrenergic blocker
Much more β-blockade than α-blockade
Effective as single agent
Clonidine ↔, ↓↑ Centrally acting α2-agonists, central sympathetic outflow.
Application: hypertension, especially with renal disease (no decrease in blood flow to kidney).
HCTZ ↔, ↓  
Vasotec ↔, ↓  
Hydralazine ↔,↑ Direct arteriolar vasodilator (watch for reflex tachycardia)
Nitroglycerin (reflex response) Venous >> arteriolar dilation
Verapamil, diltiazem conduction velocity, ERP, PR interval.
Used in prevention of nodal arrhythmias (e.g., SVT)
Nicardipene ↔, ↓ Calcium channel blocker
Peripheral vascular resistance
Cerebral vasospasm (good for stroke syndromes)
Phentolamine Pure α-blocker
Orthostatic hypotension, Vomiting, Diarrhea, flushing, wheezing.

Drugs by Disease

Clincal Scenario Goal of Tx 1st line Rx Comments
Hypertensive Encephalopathy 20-25% reduction in MAP over 2-3hr (but keep dBP>100 mmHg) -Nitroprusside 3-4 mcg/kg/min IV (max 10mcg/kg/min x 10min)
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Treatment may worsen neuro function.
Avoid Clonidine, bb (CNS effects)
Ischemic Stroke if BP ?220/120, lower 15-25% in first day -Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Nitropruside, Fenoldopam, NTG may incr. ICP.
Goal: 185/110 if thrombolytics
Intracerebral Hemorrhage Gradually reach 160/80
MAP < 110
CPP >60 w/ ICP monitor
or prestroke level
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
-Nitroprusside 3-4 mcg/kg/min IV (max 10mcg/kg/min x 10min)
-Nicardipine 5 mg/h IV, incr. 2.5mg/h q5-15min prn (Max: 15mg/h)
Monitor for worsening neuro function after lowering BP
Subarachnoid Hemorrhage same as intracranial hem. -Nimodipine 60mg PO/NGT q4h (to prevent spasm)
+/-
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
AVOID Nitropruside, Fenoldopam & NTG (incr. ICP)
Pulmonary Edema dBP <100 or resolution of Sx -Nitroprusside 3-4 mcg/kg/min IV (max 10mcg/kg/min x 10min)
+
-NTG 5mcg/min IV & incr. 5mcg/min q3-5min until response
+
-Lasix 40mg IV x1.
Avoid (-) ionotropes in LV dysfunction.
Search for myocardial ischemia. In CAD or PAD, seek RAS
MI or Unstable Angina dBP <100 or resolution os Sx NTG, BB.
Add SNP if dBP remain elevated
 
Aortic Dissection sBP 100-120 or MAP 80 (watch urine output) -Nitroprusside 3-4 mcg/kg/min IV (max 10mcg/kg/min x 10min)
or
-Clevidipine 1-2 mg/h IV, double rate q90sec until near BP goal, then incr. by smaller increments q5-10min; (max: 32 mg/h, 500 mg/24h)
or
-Fenoldopam 0.025-0.3 mcg/kg/min IV, titrate by 0.05-0.1 mcg/kg/min q15min; (max: 1.6 mcg/kg/min); Short term use up to 48 hr
PLUS
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)
Decrease sp/dT, Avoid vasodilator drugs
Sympathomimetic Crisis:
[Cocaine, amphetamines, pheochromo-cytoma, MAOI reaction, bb or clonidine withdrawal]
dBP~ 100-105 (but <25% reduction in presenting BP) over 2-6h Phentolamine (1st) 5mg IV/IM, then
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose)

Benzodiazapine:
- Ativan 1mg IV/IM for cocaine-like drugs.

Alt: NTG +/- CCB
Avoid BB or Labetolol alon (unopposed alpha stimulation)
Restart BB or Clonidine if withdrawing.
Pregnancy (eclampsia) dBP 90-105 or MAP < 126 Hydralazine 10-20mg IV q30min
-Labetalol 20mg IV x1, may give 40-80mg IV q10min. (max: 300mg/total dose).
-Nifedipine10-20mg PO
PO: methyldopa.
Avoid: SNP, ACEI
Postoperative PreOp BP SNP, Labetolol, Diuretics Tx pain, Volume overload & decrease O2
Acute renal insufficiency sBP ~ 100-105 (but <25% reduction in presenting BP) Fenoldopam, CCB, BB, Clevidipine, Clonidine. Avoid diuretics. Maintain renal  blood floww