Part 2 of my discussion with Dr. Joel Yaphe, residency program director & Dr. Claire Atzema, cardiovascular EM researcher. Hypertensive emergencies are a grab bag of diagnoses that all need to be treated differently. Hypertensive Encephalopathy, Aortic Dissection, Acute Pulmonary Edema, Pre-eclampsia & Eclampsia, Acute Renal Failure, Subarachnoid Hemorrhage and Intracranial Hemorrhage all need individualized management. In this episode these are just some of the questions I ask:
Q: What are the general principals we should go by when considering rapid BP reduction in the ED?
1. BP should almost never be rapidly lowered (except in aortic dissection)
2. Lower BP by no more than 25%, to avoid ischemia in organs auto-regulated to higher BP
3. Therapies that correct the cause (e.g. phentolamine if the BP is elevated by catecholamines) will be most effective
4. Treat to symptom resolution rather than a specific BP number
Q: Is one IV antihypertensive any better than another?
According to a Cochrane review of 15 RCTs (869 pts), there was no evidence that any class of IV antihypertensive drugs reduces mortality/morbidity, and no superiority was found among drug classes(1). The CLUE trial (2) has since shown advantages of nicardipine (faster BP reduction, less hypotension, bradycardia and AV blocking were observed) over labetolol for treatment of acute hypertension with end organ damage.
Q: What is your drug of choice for hypertensive encephalopathy, aortic dissection & pre-eclampsia?