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REF:  ACP Medicine Best Dx/Best Rx 2006   |     BP Medications   |  HypertensionRx2008  

Essential Hypertension (Keep BP < 130/80)                

See also  Hypertension Crisis  | Secondary Hypertension     

Essential Hypertension:

Secondary Hypertension

Lab Tests hypertension screening:
1.  Potassium (electrolytes), BUN, Creat, glucose, calcium, UA, TSH, CBC
2. Identify CV risk factors: lipid profile, glucose
3. Identify target-orgen injury: chest x-ray, ECG, UA, BUN, Creat, uric acid

Screening Tests for Secondary Hypertension:  see Secondary Hypertension section

The Reference Card of the Joint National Committee (JNC VII) 2003

BP Scheme for Adults (in mm Hg)

The Essential Points of JNC 7:

Lifestyle Modification

Treatment for Patients with Essential Hypertension

Initial Drug Choices

1. Uncomplicated Hypertension:  Diuretics, ACE-I, Beta-blockers

2. Compelling Indications  for Individual Drug Classes, unless contraindicated:
In Diabetes:  ACE-I, HCTZ, BB, ARB, CCB
In Chronic Kidney Disease:
In CHF:  ACE-I, diuretics, BB, ARB, Aldactone
In recurrent stroke prevention:
In isolated systolic HTN (older pts):  diuretics, Ca-blockers (long-acting Dihydropyridine)
In post Myocardial Infarction:  Beta-blocker (non-ISA), ACE-I , Aldactone
In high CVD risk:
In prostatism (BPH):  Alpha-blockers

Medications for Hypertension

* Remember to emphasize lifestyle modification (e.g., low-salt diet, regular physical activity, weight control, off smoking, etc.) and medication adherence.
  • Hydrochlorothiazide/Esidrix 12.5,  25, 50 mg tab/day      
  • Maxzide-25 (HCTZ 25 mg/ triamterene 37.5 mg) once/day
  • Dyazide (HCTX 25 mg/ triamterene 50 mg) once/day
  • Triamterene/Dyrenium 25-100 mg
  • Ethacrynic acid  (Edecrin)- Initial dose: 25 mg/day PO; range: 25–100 mg/day PO; 0.5-1 mg/kg IV (max 50 mg IV) for edema.
    Only non–sulfa-based diuretic, an alternate diuretic in renal insufficiency or sulfa-based diuretic allergy
  • Aldactone (Spironolactone) 25, 50, 100 mg tab 2-3x/day; Potassium sparing, watch for hyperkalemia, gynecomastia.
  • Modurectic (amiloride 5 mg/ HCTZ 50 mg) once/day
  • Amiloride HCl/Midamor 5-10 mg
  • Lasix (Furosemide) 20, 40, 80 mg tab 1-2x/day PO or IV
  • Bumex (Bumetanide) 0.5, 1, 2 mg tablets; 0.5-2 mg once/day PO;  IV or IM 0.5- 1 mg initially (max=10 mg/d) ;  2-10 ml vials(0.25 mg/ml)
  • Zaroxolyn (metolazone) 1.25-2.5-5 mg 1x/d  
  • Lozol (Indapamide) 1.25 - 2.5 mg tablet 1x/d  


ACE INHIBITORS - Angiotensin Converting Enzyme Inhibitor
Indications: Patients with Hypertension, CHF, Kidney disease, Diabetes, Cardiovascular disease, Heart Attack, Diabetes prevention, ? stroke.
  • Lisinopril (Zestril/Prinivil) 5, 10, 20, 40 mg tablets Start 10 mg/d; usual dose 10-40 mg/d once daily    
  • Prinzide (Lisinopril/HCTZ) 10-12.5, 10-25, 20-12.5, 20-25 tab - 1-2 tab daily. 
  • Captopril (Capoten) 12.5, 25, 50, 100 mg tab 12.5-50 mg 2-3x/day; Max:100-150 mg 2-3x/d
  • Benazepril (Lotensin) 5, 10, 20, 40 mg tablets Start 10 mg/d; usual dose 20-40 mg/d once daily
    Lotrel (Amlodipine/Benazepril)
    2/5/10. 5/10, 5/20, 10/20, 5/40, 10/40 tab
  • Cilazapril ( Inhibase) 1, 2.5, 5 mg tab  Initial dose 1.25-2.5 mg PO qd, usual dose 2.5-5 mg qd, Max 10 mg qd 
  • Enalapril (Vasotec) 2.5, 5, 10, 20 mg tablets 2.5-20 mg/d once daily.
  • Fosinopril (Monopril) 10 mg tablet Start 10 mg once/d; usual 20-40 mg/d once daily
  • Moexipril  (Univasc) 7.5, 15 mg tab. Start 7.5 mg qd PO, usual dose 7.5 - 30 mg/day   (max 30 mg/d)
  • Perindopril erbumine (Acceon) 4-8 mg once daily
  • Quinapril (Accupril) 5,10, 20, 40 mg tab -  Start 10 mg qd, usually 20-80 mg qd or in divided bid dose.  Max 80 mg/d
  • Ramipril (Altace) 1.25, 2.5, 5, 10 mg cap - Start with 2.5 mg once daily up to 20 mg/d (once or in 10 mg bid)
  • Trandolapril (Mavik) 1, 2, 4 mg table once daily.

ARB - Angiotensin II Receptor Blockers


  • Blocadren (Timolol) 5 10 20 mg tab usual dose 10 20 mg bid; max: 60 mg/d
  • Brevibloc (Esmolol) 80 mg bolus over 30 sec, then 12 mg/min IV infusion (150 ug/kg/min) for perioperative stress related tachycardia or hypertension.
  • Bystolilc (Nebivolol) start at 5 mg daily, may be increased at 2-week intervals up to 40 mg daily.    
    Unique mechanism of action includes cardioselective beta blockade and vasodilation
  • Coreg (Carvedilol) 3.125,  6.25,  12.5,  25 mg PO bid for CHF or HTN.
  • Corgard (Nadolol) 20 40 80 120 160 mg tab Start 40 mg once daily, usual dose 40-80 mg/d upto 160-240 mg/d
  • Inderal (Propanolol) 10 20 40 60 80 mg tab, 60 80 120 160 mg LA cap 20 80 mg 2 3x/d
  • Lopressor (Metoprolol) 50 100 mg tab; 5 ml (=5 mg) amp Initial dose 100 mg/d once or in divided doses; Max<450 mg/d In early MI Rx, may give 5 mg IV bolus x3, then PO 50 mg q6h x2d, then 100 mg bid PO as tolerated.
  • Toprol XL (Metoprolol) 50 100 200 mg tab Initial dose: 50 100 mg/d; max:<400 mg/d
  • Normodyne (Labetalol) 100, 200, 300 mg tab.  Start 100 mg bid, usual dose 200-400 mg bid PO.
    IV bolus 20 mg slowlyu over 2 min, additional 40 or 80 mg can be given at 10 min interval until desired BP achieved.  Max. effect usually occurs within 5 min of each injection.  Max. dose 300 mg total IV.  Half life is 5-8 hours.
    IV infusion 200 mg in 200 mL fluid at the rate of 2 mg=2mL/min, rate to be adjusted to control BP, then stop IV infusion, & change to PO Labetalol 200-1200 mg bid
  • Sectral (Acebutolol) 200 400 mg cap Start with 200 mg bid; optimal PVC response 600 1200 mg/d. Use in elderly: doses >800 mg/d should be avoided.
  • Tenormin (Atenolol) 25 50 100 mg tablets .  50- 100 mg once/d
  • Visken (Pindolol) 5, 10 mg tab.  Start 5 mg bid, max. 60 mg/day
  • Ziac (Bisoprolol) 2.5,  5,  10 mg with HCTZ 6.25 mg once daily for BP

Management of Beta-blocker overdose:

  • Cardiac pacing (pace-maker): for any symtomatic or significant bradycardia.
  • Atropine
    Hypotension: 0.5-1 mg IV with repeated doses at 5-min intervals until desired response
    Cardiac arrest: 1 mg IV repeated at 3- to 5-min intervals; minimal dose: 0.5 mg IV
    Maximal dose: 0.04 mg/kg IV or 3 mg IV is fully vagolytic
  • Isoproterenol (Isuprel)
    Adult Dose 2-4 mcg/min IV; titrate to effect  
  • Glucagon
    DOSE: 3-10 mg IV bolus followed by 2-5 mg/h infusion
    Contraindications Documented hypersensitivity; pheochromocytoma
    * Glucagon increases heart rate and myocardial contractility, and improves atrioventricular conduction. These effects are unchanged by the presence of beta-receptor blocking drugs. This suggests that glucagon's mechanism of action may bypass the beta-adrenergic receptor site. Because it may bypass the beta-receptor site, glucagon can be considered as an alternative therapy for profound beta-blocker intoxications. The doses of glucagon required to reverse severe beta-blockade are 50 micrograms/kg iv loading dose, followed by a continuous infusion of 1-15 mg/h, titrated to patient response. Glucagon-treated patients should be monitored for side effects of nausea, vomiting, hypokalemia, and hyperglycemia. The high cost and limited availability of glucagon may be the only factors precluding its future clinical acceptance.  []
  • IV hydration for hypotension
  • Gastric decontamination: Gastric lavage, with appropriate protection of the airway, is preferred over emesis because of the rapid absorption and occasionally precipitous onset of toxicity that may place the patient at risk for aspiration. Gastric lavage may be beneficial if the patient presents to the ED within 1-2 hours of ingestion. Volunteer studies have indicated that multiple dose activated charcoal (MDAC) may be useful in reducing bioavailability of nadolol, probably by removal of the drug through the enterohepatic circulation.
  • Enhanced elimination: Hemodialysis may be useful in severe cases of atenolol overdoses because atenolol is less than 5% protein bound and 40-50% is excreted unchanged in urine. Nadolol, sotalol, and atenolol (low lipid solubility, low protein binding) reportedly are removed by hemodialysis. Acebutolol is dialyzable. Propranolol, metoprolol, and timolol are not removed by hemodialysis. Consider hemodialysis or hemoperfusion only when treatment with glucagon and other pharmacotherapy fails.
  • Benzodiazepines are the drugs of choice if seizures occur.




  • Calan/Isoptin (verapamil) 80-120 mg tablets usual dose 80-120 mg tid
    Calan SR/Isoptin SR (verapamil) 120-180-240 mg tablets usual dose 120-360 mg daily
  • Cardizem (diltiazem) 30-60-90-120 mg tablets tid PO or
    Injectable IV bolus for control of heart rate in atrial fibrillation or flutter.
    Start with 0.25 mg/kg (ave=20 mg), may repeat in 15 min with 0.35 mg/kg (ave=25 mg), then infusion 5-15 mg/hr up to 24 hr.   Onset: 3 min Duration 1-3 hr.  
    (*** Not to be used in WPW or short PR syndrome. Caution should be used in CHF pts.)
    Cardizem CD (diltiazem) 180- 240- 300 mg cap 1 cap daily
    Cardizem SR (diltiazem) 60- 90- 120 mg cap
    Dilacor XR (diltiazem) 180- 240 mg cap 1 cap daily
    Tiazac (Diltiazem) 120, 180, 240, 300, 360 mg extended release cap for BP
  • Posicor/mibefradil (T-channel Ca antagonist)  50-100 mg


  • Cardene (nicardipine) 20 -30 mg capsules 20- 30 mg tid
    Cardene SR (nicardipine) 30- 45- 60 mg capsules 30- 45 -60 mg 1 cap bid
  • DynaCirc (isradipine) 2.5- 5 mg capsules 2.5 5 mg bid
  • Nimotop (nimodipine) 30 mg cap 60 mg q4h PO for 21 days, preferably >1h before or 2h after meal.
  • Norvasc (Amlodipine)  2.5,  5,  10 mg tab.  Usually 5-10 mg/day
  • Plendil (felodipine) 5- 10 mg tablets Start 5 mg/d once a day; usual dose 5 10 mg/d; max 20 mg/d
  • Procardia (nifidipine) 10 -20 mg cap 10 -20 mg tid, up to 20- 30 mg 3 4x/d.
    Procardia XL (nifidipine)
    30- 60- 90 mg tablets. usual dose 30- 90 mg once daily
  • Sular (Nisoldipine) 10, 20, 30, 40 mg tab once/day.

Management of Calcium Blocker Overdose/Toxicity:

Aggressive cardiovascular support is necessary for managing the massive calcium channel blocker overdose. While calcium chloride in high doses (4-6 g) may overcome some of the adverse effects of CCBs, it rarely restores normal cardiovascular status. According to many case reports, glucagon and inamrinone (formerly amrinone) have been used with good results. However, vasopressors are frequently necessary for adequate resuscitation and should be started early if hypotension occurs (see Medication). Additional basic overdose management includes airway protection, gastric lavage, and activated charcoal.

  • Administer glucagon (5-15 mg IV bolus) followed by an infusion after fluid resuscitation is performed for persistent hypotension. Recommended infusion rate for adults is 10-15 mg/h. Recommended pediatric dose is 50 mcg/kg IV over 5 minutes, followed by an infusion at 0.07 mg/kg/h.
  • Calcium chloride (1-4 g IV, slowly) can be administered for hypotension or heart block.
  • Thirty mL of 10% calcium gluconate can be administered over 10-15 minutes. Boluses may be repeated every 15-20 minutes for a total of 3 doses. After the third bolus, the ionized calcium level should be checked. Recommended pediatric dose of calcium gluconate is 60 mg/kg, with a maximum dose of 1 g.
  • Vasopressor support to maintain blood pressure and cardiac output is critical. In the hypotensive patient, administer dopamine at medium-to-high doses early for cardiac contractility for heart rate support and norepinephrine for blood pressure support. Inamrinone (Amrinone) may be of additional benefit in profound cardiac contractile failure.
  • In a series of case reports, high dose insulin infusion (0.1-1 U/kg/h) with dextrose infusion (usually D10W-D25W) to maintain normal serum glucose levels have been successful for stabilizing cardiac output. When using this technique frequent monitoring of glucose and potassium every 20-30 minutes is necessary.


  • Cardura (Doxazosin mesylate) 1 2 4 8 mg tab Start with 1 mg, dose:1 16 ng once daily
  • Hytrin (Terazosin) 1- 2- 5 mg tab Start 1 mg/d, usual dose 1- 5 mg once a day; max: 20 mg/d
  • Minipress (Prazosin) 1- 2- 5 mg cap Start 1 mg 2- 3x/d, usual dose up to 20 mg/d in divided doses.

Combined alpha- & Beta-blockers:

Central alpha-agonist

  • Clonidine/Catapres 0.2-1.2 mg/day; or Catapres-TTS-1, -2, -3 patch weekly
  • Methyldoma/Aldomet 500-3,000 mg/day
  • Guanabenz/Wytensin 8-32 mg/day
  • Guanfacine/Tenex 1-3 mg/day


Direct Vasodilators  
  • Hydralazine/Apresoline 50-300 mg/day
  • Minoxidil/Loniten  5 - 100 mg/day
  • Nitroglycerin 2.5, 6.5, 9 mg cap  bid


Peripheral agents
  • Reserpine/Serpasil 0.1,0.25,1.0 mg tab. Usual dose 0.1-0.5 1-2x/d;
  • Hydropress-25 (reserpine 0.125 mg + Hctz 25 mg ); 
  • Guanadrel/Hylorel 10-75 mg/day
  • Guanethidine/Ismelin 10-150 mg/day

Hypertension Crisis


  • Severe elevation in blood pressure, with diastolic blood pressure (DBP) > 120-130 mmHg.
  • Hypertensive Emergency is defined as a clinical setting where BP must be reduced effectively within minutes to <1hour, such as
    accelerated & malignant hypertension, hypertensive encephalopathy, & severe diastolic hypertension (120-160 mmHg) that is associated with acute pulmonary edema, ischemic chest pain, dissecting aortic aneurysm, or intracerebral hemorrhage,  papilledema (+/ ), evidence of renal function deterioration, or evidence of neurologic dysfunction, etc.
  • Hypertensive Urgency is defined as a clinical setting of severe hypertension  with minimal or no symptoms, where severe elevation of BP are not causing immediate end-organ damage but should be effectively lowered within 24 hours to reduce potential risk to the patient.

Symptoms as:

  • Headache, Visual Changes, Papilledema
  • Chest Pain (MI), Pain to Back (Dissection)
  • Abdominal Pain - abdominal aneurysmal dissection
  • Flank Pain - renal disease
  • Mental Status Changes - stroke, leukoencephalopathy

ACP PIER 2006                                                                      

Approach to Hypertensive Emergency/Crisis          

Distinguish between a hypertensive emergency and a pseudocrisis in patients with markedly elevated BP.

  • Do not use parenteral or sublingual drugs to treat markedly elevated BP (>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive target organ damage.
  • Use the following treatment approaches:
    • Administer one or more rapid-onset oral antihypertensive drugs (e.g., furosemide, propranolol, captopril, clonidine, or nicardipine);
      once BP is less than 180/110 mm Hg
      , administer a longer-acting formulation and recheck the BP within 48 hours.
    • Administer a longer-acting oral formulation from the start and recheck BP in 48 hours.

Identify when a hypertensive BP reading may constitute an emergency.

  • Measure BP repeatedly and assess the possibility of ongoing or imminent target organ damage.
  • Consider hospitalizing a patient with hypertensive emergency for parenteral antihypertensive medication when BP is sufficiently elevated to cause target organ damage (imminent) or is judged to have caused or played a role in present (ongoing) target organ damage.
    Specifically, considering hospitalizing hypertensive patients with:
    • Coronary disease and crescendo angina
    • Heart failure with increasing shortness of breath
    • Abrupt worsening of renal function
    • Headache, blurred vision, and increasing disorientation or confusion
    • Past hypertensive end-organ damage
    • Recent vascular surgery
    • Organ transplantation
    • Known aortic aneurysm or a tearing sensation between the scapulae
  • A child with previously normal BP may have a hypertensive emergency at a BP not considered particularly worrisome in an adult. Use clinical judgment to determine need for hospitalization.
  • A pregnant woman with previously normal or low BP may have a hypertensive emergency at a BP not considered particularly worrisome in a nonpregnant adult. Use clinical judgment to determine need for hospitalization.
  • Measure the BP more than once or twice and carefully track it before declaring an “emergency.” The duration of this tracking will vary according to clinical presentation.
  • Monitor the BP in a setting where intravenous antihypertensive drugs can be given rapidly.

Quick Exam in Severe Hypertension   Yes or  No

  • Are pressures equal in the arms?
  • Are femoral pulses present?
  • Is grade III or IV retinopathy present?
  • Is the patient oriented?
  • Are pupils equally dilated?
  • Is the neck stiff?
  • Are rales or an S3 present?
  • Are abdominal bruits present?
  • Are there overt neurologic deficits?

Quick History in Severe Hypertension     Yes or No

  • Was antihypertensive therapy recently interrupted?
  • Are neurologic symptoms present?
  • Were they sudden in onset: i.e., over minutes to hours?
  • Did they occur gradually over days?
  • Is severe headache present?
  • Have visual disturbances occurred?
  • Has nausea or vomiting occurred?
  • Is severe dyspnea present?
  • Is the patient pregnant?
  • Does the patient have worsening angina?
  • Is the patient post- vascular surgery (including CABG)?
  • Has the patient taken sympathomimetics or cocaine?
  • Is the patient taking a MAOI antidepressant ?

Situations In Which Severe Hypertension Constitutes a Crisis

  • Heart/Vascular
    • Left ventricular failure
    • MI
    • Unstable angina
    • After vascular surgery or CABG
    • Aortic dissection
  • Brain
    • Hypertensive encephalopathy
    • Subarachnoid hemorrhage
    • Intracranial hemorrhage
    • Thrombotic stroke with severe hypertension
  • Miscellaneous
    • Severe catecholamine excess:
      • Pheochromocytoma
      • Clonidine withdrawal
      • Tyramine/MAOI interaction
      • LSD/cocaine/phencyclidine/phenylpropanolamine use
    • Eclampsia in pregnancy

Antihypertensive Agents That Are Useful in Hypertensive Crises to guide treatment of patients with:

  • Markedly elevated BP and high intracranial pressure
  • Progressive azotemia
  • Coronary ischemia
  • Acute left ventricular failure
  • Eclampsia
  • Suspected aortic dissection
  • Catecholamine excess
  • Suspected aortic dissection, and in the perioperative setting


Antihypertensive Agents That Are Useful in Hypertensive Crises
  • Nitroprusside (Nipride)  IV 
    Initial dose 0.3 µg/kg/min (Max dose 10µg/kg/min) Onset of action <1 minute, duration <2 minutes
    Best use for  Encephalopathy, left ventricular failure, aortic dissection (with ?-blocker)
    Major side effects: Cyanide/thiocyanate toxicity (thiocyanate level>10 mg/dl is toxic; >20 mg/dl may be fatal) ; hypotension, N&V, apprehension, convulsion, twitching, psychosis, dizziness, etc.   It has decreased efficacy in renal failure
  • Nitroglycerin IV
    Initial dose 5 µg/min (Max dose 100 µg/min) Onset of action <5 minutes, duration <5 minutes
    For use for Unstable angina, MI.  Excellent for titrating blood pressure in setting of coronary ischemia
    Major side effect: headache, tachycardia, vomiting, methemoglobinemia
  • Labetalol (Trandate) IV
    Mixed alpha/beta blocker, excellent for most hypertensive emergencies.
    First or second line for eclampsia; excellent in catecholamine surges
    Initial dose :20 mg IV bolus over 2 minutes, then 20- 80 mg q10 min prn, or Continuous infusion at 0.5-2.0 mg/min (Max dose 300 mg),
    Onset of action <5 minutes, duration 1-4 hours, but variable
    Best use for Stroke, intracranial hemorrhage
    Side effects: Nausea Fatigue, dizziness, scalp tingling
    Contraindication: Asthma or bronchospasm, overt cardiac failure, >first-degree heart block, severe bradycardia
  • Diazoxide (Hyperstat) IV
    Initial dose: 1-3 mg/kg (up to 150 mg) IV bolus q5-15 min over 5 minutes until BP is controlled (Max dose 600 mg),
    Onset of action <2 minutes, duration 6-12 hours
    Side effects: — Profound hypotension Elevated heart rate, elevated glucose, sodium retention
    Contraindication: Thiazide allergy
  • Nicardipine (Cardene) IV
    Initial dose: 5 mg/h (Max dose 15 mg/h), Onset of action <1 hour, duration <1 hour
    Best use for Vascular surgery, subarachnoid hemorrhage  
    Side effects: Headache ,Elevated heart rate
    Contraindication: Severe aortic stenosis
  • Enalapril (Vasotec) IV
    Highly variable response; precipitous BP drop in high-renin states, rarely angioedema, hyperkalemia, or acute renal failure.
    Initial dose: 1.25 -5mg IV over 5 min q6h if needed, duration 6 hours
    Best use for Left ventricular failure
    Contraindication: Angioedema
  • Diltiazem (Cardizem) IV
    Initial dose 0.25 mg/kg over 2 min, followed by infusion of 0.35 mg/kg at an initial rate of 10 mg/hour
    Onset:  3-30 min
    Adverse effects: excessive hypotension, flushing
  • Trimethaphan
    Initial dose: 1 mg/min (Max dose 4 mg/min), Onset of action <5 minutes, duration <10 minutes
    Best use for Aortic dissection (with ?-blocker)
    Side effect: Orthostatic hypotension
    Contraindication: Severe volume depletion
  • Hydralazine (Apresoline) IV
    Indicated primarily for eclampsia
    Dose is 10-50 mg IV or IM titrate to effect (onset <20 minutes, duration 3-8 hours)
    Can be given IM as well, 10-50mg (onset 20-30 minutes)
    Onset: 10- 20 min ;  Duration: 3 -8 h
    Adverse effects: tachycardia, flushing, contraindicated in angina or aortic dissection
  • Phentolamine
    Mainly for catecholamine surges as in pheochromocytoma hypertension (pure alpha-adrenergic blockade)
    Dose is 5-15mg IV; onset 1-2 minutes; duration 3-10 minutes
    Side effects: Tachycardia, flushing and headache may occur
  • Esmololol (Breviblock®)
    Mainly for acute aortic dissection, perioperatively, acute coronary ischemia

    May be used with caution in acute MI with depressed LV to modulate heart rate
    Very short half life (2-4 minutes) non-selective ß-blockade
    Dose is 250-500µg/kg/min for 1 minute, then 50-100µg/kg for 4 minutes
    Sequence may be repeated, and continuous drip may be maintained
    Onset of action is 1-2 minutes; 10-20 minute duration
    Very close monitoring is required, and fluid load is large with this agent

Oral Medications for Hypertensive Urgency:

  • Clonidine (Catapres)
    0.2 mg PO, followed by 0.1 mg/hr to total of 0.8 mg until the diastolic BP is <110 mmHg, or reduction in diastolic BP of 20 mmHg or more.
    Onset 30-120 min;  Duration 8-12 h
    Adverse effects: sedation, dry mouth, dizziness, orthostasis, bradycardia
    Contraindicated in pts with sinus bradycardia, sick sinus synd., or heart block.
  • Labetalol (Trandate)
    200-300 mg PO, followed by 100-200 mg q8h
    Onset 1-2h;  Duration 12-24 h
    Adverse effects: bradycardia
  • Furosemide (Lasix)
    20-40 mg PO or IV
  • Nicardipine (Cardene)
    20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase by 2.5 mg/h q5-15 min to max 15 mg/h.
  • Captopril (Capoten)
    12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical dose <150mg/d; Max 450 mg/d)


Distinguish between a hypertensive emergency and a pseudocrisis in patients with markedly elevated BP.

  • Do not use parenteral or sublingual drugs to treat markedly elevated BP (>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive target organ damage.
  • Use the following treatment approaches:
    • Administer one or more rapid-onset oral antihypertensive drugs (e.g., furosemide, propranolol, captopril, clonidine, or nicardipine);
      once BP is less than 180/110 mm Hg
      , administer a longer-acting formulation and recheck the BP within 48 hours.
    • Administer a longer-acting oral formulation from the start and recheck BP in 48 hours.

In less than hypertensive crises, but  in hypertension urgency:
one or more rapid-onset oral antihypertensive drugs, as:

  • Furosemide (Lasix) 20-40 mg PO or IV
  • Clonidine 01.-0.2 mg PO
  • Nicardipine (Cardene) 20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase by 2.5 mg/h q5-15 min to max 15 mg/h.
  • Captopril 12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical dose <150mg/d; Max 450 mg/d)


Causes of Hypertensive Crisis 
  • Chronic hypertension with acute exacerbation (most common)
  • Renovascular hypertension
  • Parenchymal Renal Disease
    • Acute glomerulonephritis
    • Renal Infarction
    • Vasculitis
  • Scleroderma Renal Crisis
  • Drug Ingestion
    • Tricyclic anti-depressants
    • Monoamine Oxidase (MAO) Inhibitors
    • Cocaine
    • Amphetamines
  • Anti-hypertensive drug withdrawal or failed compliance
    • Centrally acting anti-hypertensives (eg. clonidine)
    • Peripheral alpha blockers (eg. prazosin)
    • Beta-Blocker acute withdrawal
  • Pre-eclampsia and Eclampsia
  • Autonomic hyperactivity
    • Guillain-Barre Syndrome
    • Spinal Cord Injury
  • Pheochromocytoma