Intravenous Therapy for Hypertensive Emergencies, Part 1

Denise Rhoney; W. Frank Peacock


Am J Health Syst Pharm. 2009;66(15):1343-1352. 

In This Article

Rationale for i.v. Antihypertensive Selection

In general, the multiple agents available for the treatment of hypertensive emergencies rapidly lower BP in patients at imminent risk of or during evolving end-organ damage.[1] The goal of drug therapy is to reduce BP in a controlled and predictable manner, while weighing the potential adverse effects of each drug on an individual basis. Both drug-specific and patient-specific factors must be considered to ensure the selection of an appropriate agent. Drug-specific factors include the drug's pharmacokinetic parameters and adverse effects. In addition, due to the potential for "overshoot" with agents like nitroprusside, arterial BP monitoring is a requirement for the use of some agents. Cost-effectiveness is another important drug-specific factor and should include consideration of the length of hospital stay, time spent in the ICU, and long-term morbidity. Unfortunately, few studies have rigorously evaluated the cost-effectiveness of pharmacologic agents for the management of hypertensive emergencies. Thus, treatment decisions cannot currently be based on perceived cost-effectiveness. A detailed description of important drug-specific factors of each agent is available in eTables 1 and 2 (accessible online at

Patient-specific factors that must be considered when selecting an appropriate drug and dose include patient age, race, pregnancy status, and volume status and the presence of end-organ disease and other comorbidities. In general, elderly patients may be more responsive to the hypotensive effects of these agents; for this reason, it is a good practice to start with a lower dose or infusion rate of these agents in patients over age 65 years. Race may be an important consideration for the use of many antihypertensives. For example, i.v. enalaprilat is most effective in treating hypertension associated with high renin levels. Thus, populations with traditionally low renin levels (e.g., African Americans) may experience smaller BP reductions than patients with high renin values. Similarly, patients with high renin levels may have large and rapid decreases in BP and should be closely monitored. Both hepatic and renal function status are important considerations with agents that rely on these organ systems for elimination or whose toxic metabolites may need elimination, such as with sodium nitroprusside.


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