Podcast 592:  Rapid Antihypertensives

Contributor: Ramnik Dhaliwal, MD, JD

Educational Pearls:

• Nitrates
• • Nitroprusside: becomes effective in under a minute, and becomes ineffective 10 minutes after stopping it. 
  • • Nitroprusside can metabolize into cyanide leading to toxicity, however this is rare.
  • Nitroglycerin: predominately causes vasodilation but some arterial dilation as well; preferred agent in patients with volume overload/CHF
• Adrenergic Blocking Agents
• • Labetalol: alpha/beta-blocking agent with a rapid onset of 5 minutes or less given as bolus or intravenous drip
  • Esmolol: cardioselective beta blocker with rapid onset and short duration of action making it easily titratable
  • Hydralazine: direct arterial dilator;  patient dependent response that can be unpredictable. Use with caution in patients with CAD or an aortic dissection because there will be a reflexive increase in heart rate to combat the arteriolar dilation.
• Calcium Channel Blockers
• • Nicardipine: Given as an IV infusion starting at 5g/hr up to 15g/hr. This drug has a slower onset of action making it difficult to titrate and it has a longer serum elimination half-life (3-6 hours)
  • Clevidipine: rapid onset and short duration of action;  Reduces BP without affecting cardiac filling pressures but can cause reflex tachycardia

References

)Wani-Parekh P, Blanco-Garcia C, Mendez M, Mukherjee D. Guide of Hypertensive Crisis Pharmacotherapy. Cardiovasc Hematol Disord Drug Targets. 2017;17(1):52-57. doi:10.2174/1871529X16666161220142020

Suneja M, Sanders ML. Hypertensive Emergency. Med Clin North Am. 2017;101(3):465-478. doi:10.1016/j.mcna.2016.12.007

Maloberti A, Cassano G, Capsoni N, et al. Therapeutic Approach to Hypertension Urgencies and Emergencies in the Emergency Room. High Blood Press Cardiovasc Prev. 2018;25(2):177-189. doi:10.1007/s40292-018-0261-4

Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD