Hypertensive Crisis in ICU

lying trigger, as 
well as improved long term outcomes after the episode.
• A detailed history, physical examination, relevant lab tests, EKG, 
echo and radiographs. 
Hypertensive Urgency:
• Pt with inadequately controlled HTN or noncompliance.
• Severe headache, epistaxis, chest pain, severe anxiety, shortness 
of breath.
Hypertensive Emergency:
• Acute coronary syndrome: unstable angina and myocardial 
infarction.
• Acute pulmonary edema.
• Acute aortic dissection.
• Pre-eclampsia and eclampsia.
• Acute renal failure.
• Catecholamine excess.
• Hypertensive encephalopathy and Stroke.
• Postoperative hypertensive crisis.
Management
Hypertensive Urgency:
• Pt can be managed in an outpatient setting or inpatient observation 
(Diabetes, Hx of stroke or CAD or medication non-compliance).
• Treated with oral antihypertensive agents. Start with very low dose 
of oral agents using incremental doses as needed. 
• Gradual and controlled reduction of BP, especially in pts with 
highest risk for hypotensive complications: the elderly, severe PVD, 
severe CAD and intracranial disease.
• Goal: reduce BP to 160/110 mm Hg over several hours to days. 
Outpatient follow up within 24-48 hrs after discharge.
Management
Hypertensive emergency:
• Require admission to in an ICU.
• Treatment must be individualized, based on the extent of end-organ 
damage as well as other comorbid conditions.
• Control BP with a parenteral, titratable antihypertensive agents to 
avoid further end organ damage.
• Continuously monitoring BP.
Management
• Goal: mean arterial pressure should not be lowered more than 20% 
over a period of several minutes or hours.
• Aortic dissection: BP must be achieved within 10 minutes (SBP 
<120 and MAP <80).
• Volume expansion with IV saline solution in the presence of 
concomitant hypovolemia.
• Caution when treating a hypertensive crisis in pts with stroke.
Parenteral agents for hypertensive emergency
1 Nicardipine:
• Dihydropyridine calcium channel blocker. Arterial vasodilator 
• Rapid onset of action (1-5 minutes), easy to use.
• Limitation: long half-life.
• Indication: all hypertensive emergencies, perioperative HTN and 
controlled hypotension during anesthesia.
2 Clevidipine:
• Short acting dihydropyridine CCBs.
• Reduce BP without affecting cardiac filling pressure or causing 
tachycardia.
• Indication: intraoperative and critical care setting.
Parenteral agents for hypertensive emergency
3 Labetalol:
• Alpha and beta blocker.
• Maintain cardiac output and reduce total peripheral resistance.
• Rapid onset (less than 5 minutes).
• Indication: all hypertensive emergency except acute heart failure.
4 Esmolol:
• Very short acting beta blocker, short half life ( 9 minutes), duration 
(30 minutes).
• Cardioselective beta blocker.
• Independent of liver and kidney function. 
• Useful for perioperative hypertensive crisis. Not recommended for pt 
with catecholamine excess.
Parenteral agents for hypertensive emergency
4 Fenoldopam:
• Peripheral dopamine-1 receptor agonist.
• Cause vasodilatation and sodium excretion without alpha 1 or beta 1 
activation.
• Maintain or increase renal perfusion.
• Does not rebound hypertension when discontinued.
• Safely used in all hypertensive emergency, particularly in pts with 
renal insufficiency.
5 Enalaprilat:
• Parenteral ACEI. Slow onset: 1hr, duration: 6hrs.
• Response: variable and unpredictable. Used in pt with heart failure, 
contraindication in pregnancy and bilateral renal artery stenosis.
Parenteral agents for hypertensive emergency
6 Nitroglycerin:
• Venodilator.
• Reduce preload and cardiac output.
• Used with other meds in pt with pulmonary edema and acute MI.
7 Nitroprusside:
• Dilates both arterioles and veins. Reduce preload and afterload.
• Rapid onset and short half life.
• Side effects: increase intracranial pressure, induce a coronary steal 
phenomenon. Cyanide toxicity.
• Used in pt with acute pulmonary edema, severe left ventricular 
dysfunction and aortic dissection.
Parenteral agents for hypertensive emergency
8 Phentolamine:
• Peripheral alpha 1 and 2 receptors antagonist.
• Used for pt with catecholamine excess, interactions between 
monoamine oxidase inhibitors and other drugs or food, cocaine 
toxicity, amphetamine overdose, or clonidine withdrawal.
• Used cautiously in patients with CAD, as it can induce angina or MI.
9 Hydralazine:
• A peripheral vasodilator.
• The unpredictability of response and prolonged duration of action do 
not make hydralazine a desirable first-line agent in pts with 
hypertensive emergencies.
Specific indications
1 Hypertensive encephalopathy:
• Cerebral hyperperfusion causing cerebral edema (auto-regulatory 
mechanism fails).
• Severe HA, nausea/vomiting, visual disorders, altered mental 
status and/or seizure. Symptoms appear progressively over 24-
48hrs.
• It may occur with or without retinopathy and proteinuria.
• CT scan of head to rule out intracranial hemorrhage.
• Gradual lowering of the blood pressure frequently leads to rapid 
improvement of neurologic symptoms. 
• Labetalol, nicardipine, fenoldopam, clevidipine.
Specific indications
2 Aortic dissection:
• Chest pain, back pain or abdominal pain with hypertension.
• Asymmetric pulses or blood pressure, a vascular murmur, an aortic 
incompetence murmur, or signs of cerebral or limb ischaemia.
• CXR: widening of mediastinum.
• CT angiogram of chest or transesophageal echocardiogram, MRI of 
chest or aortography.
• Achieve an SBP < 120 mmHg within 10 minutes. 
• Labetalol alone or a combination of Beta Blocker with a vasodilator 
(increased shear stress in the vessel wall).
Specific indications
3 Acute coronary syndrome:
• Unstable angina and myocardial infarction.
• HTN causes increased myocardial stress and oxygen consumption.
• Chest pain, changes in EKG and elevated cardiac enzymes.
• Nitroglycerin with esmolol, fenoldopam, labetalol.
Specific indications
4 Acute pulmonary edema:
• HTN crisis: causative or aggravating factors.
• Shortness of breath, chest pain.
• CXR: vascular congestion, cardiomegaly.
• Loop diuretic, Enalaprilat, nitroglycerin, nitroprusside.
Specific indications
5 Pre-eclampsia and eclampsia:
• Hypertension may be present before pregnancy or after the 
twentieth week of pregnancy.
 Pre-eclampsia: HTN, proteinuria; HELLP
predisposing factors: DM, twin pregnancy, molar pregnancy etc.
 Eclampsia: severe pre-eclampsia with seizure.
• Close monitoring.
• Indication for induction of labor.
• Labetalol, hydralazine, nicardipine (caution with magnesium sulfate).
Specific indications
6 Acute renal failure:
• May be the cause or a consequence of HTN emergency.
• Worsen preexisting renal failure. Increase in extracellular volume 
and vasoconstriction due to RAAS activation.
• Nicardipine, fenoldopam.
7 Postoperative hypertentive emergency:
• Occurs in early postoperative period. 
• Due to adrenergic mechanism.
• Nicardipine, nitroprusside, esmolol and labetalol.
Specific indications
8 Pheochromocytoma and catecholamine excess:
• Pheochromocytoma can cause paroxysmal HTN: pulsatile HA, 
sweating and palpitation. Highly suggestive of the disease if pt has 
orthostatic hypotension.
• Catecholamine excess: ingestion of tyramine containing foods with 
taking monoamine oxidase inhibitors, withdrawal of central acting 
antihypertensives, illicit drug use.
• Risk of sudden death from arrhythmia and cardiogenic shock.
• Nicardipine , labetalol, nitroprusside. Pure beta blocker is 
contraindicated. Bezodiazepine is adjuvant therapy in these cases.
Specific indications
9 Stroke:
• HTN during acute stroke could be a physiological response to 
maintain adequate cerebral perfusion.
• In hemorrhagic stroke: disruption of autoregulatory mechanism of 
bled area, blood flow and oxygen delivery depending on systemic 
perfusion pressure.
• Cerebral perfusion pressure = MAP – ICP.
• In ischemic stroke: perfusion pressure distal to obstructed vessel is 
low and a mechanism of compensatory vasodilatation of these 
vessels to maintain perfusion.
• Subarachnoid hemorrhage increases risks of intracerebral 
hemorrhage and hydrocephalus.
• MAP should not be lowered than more than 20-25% of the previous 
level.
• BP is carefully controlled. 
• Nicardipine, fenoldopam, labetalol and clevidipine.
Take home messages
• Distinguishing between hypertensive urgency and emergency is 
very important for appropriate treatment.
• A complete evaluation of pt with hypertensive crisis is to detect and 
reverse the crisis and avoid further target organ damage.
• Hypertensive emergency needs to be admitted to ICU for close 
monitoring of blood pressure and using parenteral antihypertensive 
drugs.
• Hypertensive urgency can be managed at outpatient setting and oral 
antihypertensive can be used.
• MAP is not lowered than 20% of initial level in few hours in 
hypertensive emeregency.
• Looking for and correcting triggering factors to improve outcomes.
References
• Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of 
the Joint National Committee on Prevention, Detection, Evaluation, 
and Treatment of High Blood Pressure: the JNC 7 Report. JAMA 
2003; 289:2560–2572.
• Rodriguez MA, Kumar SK, Caro MD. Hypertensive Crisis. 
Cardiology in Review. Vol 18, No 2, March/April 2010.
• Michel Slama and Santhi Smay Modeliar. Hypertension in the 
intensive care unit. Curr Opin Cardiol 21: 279-287.
• Sheldon Hirsh. A different approach to resistant hypertension. 
Cleveland clinic journal of Medicine: vol 74, No 6; June/2007.
• Katakam R, Brukamp K, Townsend RR. What is the proper workup 
of a patient with hypertension. Cleveland clinic journal of Medicine. 
Vol 75, No 9, Sept 2008.
• Vaidya CK,Ouellette JR. Hypertensive Urgency and Emergency. 
Hospital Physician. March 2007.