HTN Medications

Drug Selection in patients w or w/o other Comorbidities:



Urgency can often be treated in clinic:

  • Goal: Reduce BP to 160/110 mm Hg over several hours to days
  • Drugs
    • Captopril: onset of action 15-30 minutes
      • Maximum drop in BP: 30-90 minutes
      • 25 mg initial dose, followed by 50-100 mg 90-120 minutes later
    • Nicardipine: onset of action 30-120 minutes
      • Usual dose: 30 mg every 8 hours until target BP achieved
      • Use of short-acting nifedipine should be avoided due to stroke risk
    • Labetalol: onset of action within 60-120 minutes
      • Starting dose 200 mg, repeated every 3-4 hours
    • Clonidine: onset of action within 15-30 minutes
      • Peak effect: 2-4 hours
      • Typical regimen: 0.1-0.2 mg loading dose, followed by 0.05-0.1 mg every hour until target BP achieved (max dose 0.7 mg)
    • Resume usual blood pressure regimen with enhanced monitoring or add additional medication if appropriate


Hypertensive Emergency:



Trends (HTN Case Slides)

Heart failure. Most hypertensive emergency patients should not take diuretics because of the dehydrating effect, but nitroglycerin and diuretics can help heart failure patients by reducing hormones causing the high blood pressure.

Acute heart failure. Don’t use labetalol because it has beta-blocking activity that can further exacerbate heart failure.

Chronic kidney disease. Avoid using an ACE inhibitor, which can make kidney function worse and cause hyperkalemia.

Aortic dissection. (An aortic dissection is a serious condition in which a tear develops in the inner layer of the aorta, the large blood vessel branching off the heart. Blood surges through this tear into the middle layer of the aorta, causing the inner and middle layers to separate (dissect). If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal.) This is a life-threatening problem, so it’s appropriate to violate the 25% rule and lower blood pressure more quickly (to below 120/80 mm Hg or less)

Ischemic stroke. Treat these patients less aggressively than guidelines suggest. There is no official consensus on whether blood pressure should be lowered at all in stroke patients because doing so may reduce cerebral blood flow.

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