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The Diagnosis and Management of Hypertensive Crises*

*+ ,o)ep$ Va"on- MD- FCCP an# .+ Pa(/ E+ Ma"ik- MD- FCCP 0A(t$o" A11i/iation) 0A(t$o" A11i/iation) 1.
*

From the Department of Medicine (Dr. Varon), Baylor College of Medicine, Hou ton !"# and the Department of $nternal Medicine, %ection of Critical Care (Dr. Mari&), 'a hington Ho pital Center, 'a hington, DC.

Ne2t Section

Abstract

Se%e"e $ pe"ten)ion i) a common c/inica/ p"o3/em in t$e Unite# State)- enco(nte"e# in %a"io() c/inica/ )etting)+ A/t$o(g$ %a"io() te"m) $a%e 3een app/ie# to )e%e"e $ pe"ten)ion)(c$ a) $ pe"ten)i%e c"i)e)- eme"gencie)- o" ("gencie)- t$e a"e a// c$a"acte"i4e# 3 ac(te e/e%ation) in BP t$at ma 3e a))ociate# !it$ en#5o"gan #amage 6$ pe"ten)i%e c"i)i)7+ T$e imme#iate "e#(ction o1 BP i) on/ "e8(i"e# in patient) !it$ ac(te en#5o"gan #amage+ H pe"ten)ion a))ociate# !it$ ce"e3"a/ in1a"ction o" int"ace"e3"a/ $emo""$age on/ "a"e/ "e8(i"e) t"eatment+ 9$i/e nit"op"())i#e i) common/ ()e# to t"eat )e%e"e $ pe"ten)ion- it i) an e2t"eme/ to2ic #"(g t$at )$o(/# on/ 3e ()e# in "a"e ci"c(m)tance)+ F("t$e"mo"e- t$e )$o"t5acting ca/ci(m c$anne/ 3/ocke" ni1e#ipine i) a))ociate# !it$ )igni1icant mo"3i#it an# )$o(/# 3e a%oi#e#+ To#a - a !i#e "ange o1 p$a"maco/ogic a/te"nati%e) a"e a%ai/a3/e to t$e p"actitione" to cont"o/ )e%e"e $ pe"ten)ion+ T$i) a"tic/e "e%ie!) )ome o1 t$e c(""ent concept) an# common mi)conception) in t$e management o1 patient) !it$ ac(te/ e/e%ate# BP+

ao"tic #i))ection :53/ocke") ca/ci(m c$anne/ 3/ocke") 1eno/#opam $ pe"ten)ion $ pe"ten)i%e c"i)e) $ pe"ten)i%e encep$a/opat$ /a3eta/o/ nica"#ipine nit"op"())i#e p"egnanc

H pe"ten)ion i) a common c/inica/ p"o3/em in t$e Unite# State)- an# p$ )ician) o1 a// t pe) a"e /ike/ to enco(nte" patient) !it$ $ pe"ten)i%e ("gencie) an# eme"gencie)+ A/t$o(g$ %a"io() te"m) $a%e 3een app/ie# to t$e)e con#ition)- t$e a"e a// c$a"acte"i4e# 3 ac(te e/e%ation) in BP+*.;<=>?@ P"ompt 3(t ca"e1(// con)i#e"e# t$e"ap i) nece))a" to /imit mo"3i#it an# mo"ta/it +A*B Un1o"t(nate/ - acce/e"ate# $ pe"ten)ion i) among t$e mo)t mi)(n#e")too# an# mi)manage# o1 Cac(teD me#ica/ p"o3/em) )een in c/inica/ p"actice+ Man p$ )ician) $a%e an ("gent nee# to "api#/ /o!e" an e/e%ate# BP !it$o(t con)i#e"ing t$e pat$op$ )io/ogic p"incip/e) in%o/%e#+ P"e%io() SectionNe2t Section

Definitions
T$e ,oint Nationa/ Committee on P"e%ention- Detection- E%a/(ation- an# T"eatment o1 Hig$ B/oo# P"e))("e $a) c/a))i1ie# $ pe"ten)ion acco"#ing to t$e #eg"ee o1 BP e/e%ation+* Stage * patient) $a%e a ) )to/ic BP o1 *<B to *=A mm Hg o" a #ia)to/ic BP o1 AB to AA mm Hg+ Stage . in#i%i#(a/) $a%e a ) )to/ic BP o1 *>B to *?A mm Hg o" a #ia)to/ic BP o1 *BB to *BA mm Hg- !$e"ea) )tage ; inc/(#e) a ) )to/ic BP p"e))("e E *@B mm Hg o" a #ia)to/ic BP E **B

mm Hg+ Stage ; $ pe"ten)ion $a) a/)o 3een ca//e# )e%e"e $ pe"ten)ion o" acce/e"ate# $ pe"ten)ion+ T$e 1eat("e) an# c/a))i1ication an# o1 p"egnanc 5in#(ce# $ pe"ten)ion a"e inc/(#e# in Ta3/e * +** A n(m3e" o1 #i11e"ent te"m) $a%e 3een app/ie# to )e%e"e ac(te e/e%ation) o1 BP+ Ho!e%e"mo)t a(t$o") $a%e #e1ine# $ pe"ten)i%e c"i)e) o" eme"gencie) a) a )(##en inc"ea)e in ) )to/ic an# #ia)to/ic BP a))ociate# !it$ en#5o"gan #amage o1 t$e CNS- t$e $ea"t- o" t$e ki#ne )F t$e te"m hyperten i(e urgencie $a) 3een ()e# 1o" patient) !it$ )e%e"e/ e/e%ate# BP !it$o(t ac(te en#5o"gan #amage+.;<=@*.*; Ta3/e . /i)t) t$o)e c/inica/ con#ition) t$at meet t$e #iagno)tic c"ite"ia o1 $ pe"ten)i%e c"i)e)+ It i) impo"tant to note t$at t$e c/inica/ #i11e"entiation 3et!een $ pe"ten)i%e eme"gencie) an# $ pe"ten)i%e ("gencie) #epen#) on t$e p"e)ence o1 ta"get o"gan #amage- "at$e" t$an t$e /e%e/ o1 BP+ Anot$e" 1"e8(ent/ enco(nte"e# te"m- malignant hyperten ion- i) #e1ine# a) a ) n#"ome c$a"acte"i4e# 3 e/e%ate# BP accompanie# 3 encep$a/opat$ o" nep$"opat$ +**< Po)tope"ati%e $ pe"ten)ion $a) a"3it"a"i/ 3een #e1ine# a) ) )to/ic BP G *AB mm Hg an#Ho" #ia)to/ic BP E *BB mm Hg on t!o con)ec(ti%e "ea#ing) 1o//o!ing )("ge" +*=*> T$e t"an)ient nat("e o1 po)tope"ati%e $ pe"ten)ion an# t$e (ni8(e c/inica/ 1acto") p"e)ent in t$e po)tope"ati%e pe"io# "e8(i"e t$at t$i) c/inica/ ) n#"ome 3e gi%en in#i%i#(a/ con)i#e"ation+ A ) )to/ic p"e))("e G *>A mm Hg o" a #ia)to/ic G *BA mm Hg in a p"egnant !oman i) con)i#e"e# a $ pe"ten)i%e eme"genc "e8(i"ing imme#iate p$a"maco/ogic management+*? P"e%io() SectionNe2t Section

Epidemiology, Etiology, Pathogenesis

H pe"ten)ion i) e2t"eme/ common in t$e Ame"ican pop(/ation+ Si2t mi//ion US in$a3itant) )(11e" 1"om $ pe"ten)ion+* T$e %a)t maIo"it o1 t$e)e patient) $a%e e))entia/ $ pe"ten)ion+ Mo"eo%e"- a /a"ge n(m3e" o1 a11ecte# in#i%i#(a/) a"e (na!a"e o1 t$ei" $ pe"ten)ion+ T$"ee 8(a"te") o1 t$o)e a11ecte# #o not $a%e t$ei" BP !e// cont"o//e#+ Fe!e" t$an *J o1 t$e)e patient) !i// #e%e/op one o" m(/tip/e epi)o#e) o1 $ pe"ten)i%e c"i)e)+*@*A T$e inci#ence o1 $ pe"ten)i%e c"i)e) i) $ig$e" among A1"ican Ame"ican) an# t$e e/#e"/ +*B*;.B.* T$e maIo"it o1 patient) p"e)enting !it$ $ pe"ten)i%e c"i)e) $a%e p"e%io()/ "ecei%e# a #iagno)i) o1 $ pe"ten)ion- an# man $a%e 3een p"e)c"i3e# anti$ pe"ten)i%e t$e"ap !it$ ina#e8(ate BP cont"o/+*B*;.B T$e inci#ence o1 po)tope"ati%e $ pe"ten)i%e c"i)e) %a"ie) #epen#ing on t$e pop(/ation e2amine#- 3eing "epo"te# in < to ;=J o1 patient) )$o"t/ a1te" t$e )("gica/ p"oce#("e+*>...; Like ot$e" 1o"m) o1 acce/e"ate# $ pe"ten)ion- a $i)to" o1 $ pe"ten)ion i) common+ P"eec/amp)ia 6p"egnanc 5"e/ate# $ pe"ten)ion7 i) a 1o"m o1 $ pe"ten)ion t$at #e)e"%e) mention+ T$e inci#ence o1 p"eec/amp)ia %a"ie) acco"#ing to t$e patient c$a"acte"i)tic)+ It occ(") in ?J o1 a// p"egnancie)+ O1 t$em- ?BJ a"e n(//5g"a%i#a) an# ;BJ a"e m(/ti5g"a%i#a)+ In mo/a" p"egnancie)- p"eec/amp)ia $a) 3een #e)c"i3e# in (p to ?BJ o1 ca)e)+.< T$e pat$op$ )io/og o1 $ pe"ten)i%e c"i)e) i) t$o(g$t to 3e #(e to a3"(pt inc"ea)e) in ) )temic %a)c(/a" "e)i)tance t$at a"e /ike/ "e/ate# to $(mo"a/ %a)ocon)t"icto")+.=.> 9it$ )e%e"e e/e%ation) o1 BP- en#ot$e/ia/ inI(" occ(") an# 1i3"inoi# nec"o)i) o1 t$e a"te"io/e) en)(e)+.=.> T$i) %a)c(/a" inI(" /ea#) to #epo)ition o1 p/ate/et) an# 1i3"in- an# a 3"eak#o!n o1

t$e no"ma/ a(to"eg(/ato" 1(nction+ T$e "e)(/ting i)c$emia p"ompt) 1("t$e" "e/ea)e o1 %a)oacti%e )(3)tance)- comp/eting a %icio() c c/e+.> It )$o(/# 3e app"eciate# t$at mo)t patient) !$o p"e)ent to $o)pita/ !it$ an e/e%ate# BP a"e Cc$"onica// $ pe"ten)i%e-D !it$ a "ig$t!a"# )$i1t o1 t$e p"e))("eH1/o! 6ce"e3"a/ an# "ena/7 a(to"eg(/ation c("%e 6Fig * 7+.? F("t$e"mo"e- mo)t patient) !it$ )e%e"e $ pe"ten)ion 6#ia)to/ic p"e))("e E **B mm Hg7 $a%e no ac(te- en#5o"gan #amage+ Rapi# anti$ pe"ten)i%e t$e"ap in t$i) )etting ma 3e a))ociate# !it$ )igni1icant mo"3i#it +.@.A;B T$e"e a"e- $o!e%e"- t"(e $ pe"ten)i%e eme"gencie) in !$ic$ t$e "api# 6cont"o//e#7 /o!e"ing o1 BP i) in#icate# 6)ee 3e/o!7+*@*A;* P"e%io() SectionNe2t Section

Clinical Manifestations
T$e mani1e)tation) o1 $ pe"ten)i%e c"i)e) a"e t$o)e o1 en#5o"gan # )1(nction+ Ta3/e . /i)t) t$o)e con#ition) t$at- !$en a))ociate# !it$ )e%e"e/ e/e%ate# BP- a"e "e1e""e# to a) $ pe"ten)i%e c"i)e)Heme"gencie)+ O"gan # )1(nction i) (ncommon !it$ #ia)to/ic BP) K *;B mm Hg- a/t$o(g$ it ma occ("+ It i) impo"tant to "ecogni4e t$at t$e a3)o/(te /e%e/ o1 BP ma not 3e a) impo"tant a) t$e "ate o1 inc"ea)e+?A;.;; Fo" e2amp/e- patient) !it$ /ong5)tan#ing $ pe"ten)ion ma to/e"ate ) )to/ic BP) o1 .BB mm Hg o" #ia)to/ic inc"ea)e) (p to *=B mm Hg !it$o(t #e%e/oping $ pe"ten)i%e encep$a/opat$ - !$i/e c$i/#"en o" p"egnant !omen ma #e%e/op encep$a/opat$ !it$ #ia)to/ic BP G *BB mm Hg+*? Hea#ac$e- a/te"e# /e%e/ o1 con)cio()ne))- an# /e))5)e%e"e #eg"ee) o1 CNS # )1(nction a"e t$e c/a))ic mani1e)tation) o1 $ pe"ten)i%e encep$a/opat$ +>? A#%ance# "etinopat$ !it$ a"te"io/a" c$ange)- $emo""$age) an# e2(#ate)- a) !e// a) papi//e#ema- a"e common/ )een on e2amination o1 1(n#i in patient) !it$ $ pe"ten)i%e encep$a/opat$ + Ca"#io%a)c(/a" mani1e)tation) o1 $ pe"ten)i%e c"i)e) ma inc/(#e angina o" ac(te m oca"#ia/ in1a"ction+ Ca"#iac #ecompen)ation ma /ea# to ) mptom) o1 # )pnea- o"t$opnea- co(g$- 1atig(e o" 1"ank p(/mona" e#ema+*B;< Se%e"e inI(" to t$e ki#ne ma /ea# to "ena/ 1ai/("e !it$ o/ig("ia an#Ho" $emat("ia+ In p"egnanc - t$e p"e)entation o1 a patient !it$ p"eec/amp)ia ma "ange 1"om a mi/# to a /i1e5 t$"eatening #i)ea)e p"oce))+ T$e c/inica/ 1eat("e) o1 )e%e"e #i)ea)e inc/(#e %i)(a/ #e1ect))e%e"e $ea#ac$e)- )ei4("e)- a/te"e# con)cio()ne))- ce"e3"o%a)c(/a" acci#ent)- )e%e"e "ig$t (ppe" 8(a#"ant a3#omina/ pain- conge)ti%e $ea"t 1ai/("e- an# o/ig("ia+ T$i) p"oce)) can 3e en#e# on/ 3 #e/i%e" + T$e #eci)ion to contin(e o" to #e/i%e" t$e p"egnanc )$o(/# 3e ma#e 3 con)(/tation 3et!een me#ica/ an# o3)tet"ic pe")onne/+**.<;= One ) n#"ome !a""anting )pecia/ con)i#e"ation i) ac(te ao"tic #i))ection+ P"opagation o1 t$e #i))ection i) #epen#ent not on/ on t$e e/e%ation o1 t$e BP it)e/1- 3(t a/)o on t$e %e/ocit o1 /e1t %ent"ic(/a" eIection+;*;> Fo" t$i) "ea)on- )peci1ic t$e"ap aime# at 3ot$ ta"get) 6BP an# "ate o1 p"e))("e "i)e7 i) (ti/i4e# 1o" t$e)e ca)e) 6)ee 3e/o!7+ P"e%io() SectionNe2t Section

Initial Eval ation of the Patient !ith Hypertensive Crises

T$e ke to )(cce))1(/ management o1 patient) !it$ )e%e"e/ e/e%ate# BP i) to #i11e"entiate $ pe"ten)i%e c"i)e) 1"om $ pe"ten)i%e ("gencie)+ T$i) i) accomp/i)$e# 3 a ta"gete# me#ica/ $i)to" an# p$ )ica/ e2amination )(ppo"te# 3 app"op"iate /a3o"ato" e%a/(ation+*A P"io" $ pe"ten)i%e c"i)e)- anti$ pe"ten)i%e me#ication) p"e)c"i3e#- an# BP cont"o/ )$o(/# 3e a)ce"taine#+ Pa"tic(/a" in8(i" )$o(/# inc/(#e t$e ()e o1 monoamine o2i#a)e in$i3ito") an# "ec"eationa/ #"(g) 6ie- cocaine- amp$etamine)- p$enc c/i#ine7+ T$e BP in all lim) )$o(/# 3e mea)("e# 3 t$e p$ )ician+ In o3e)e patient)- app"op"iate/ )i4e# c(11) )$o(/# 3e ()e#+ F(n#()copic e2amination i) man#ato" in a// ca)e) to #etect t$e p"e)ence o1 papi//e#ema+ A CBC co(nt- e/ect"o/ te)- BUN- c"eatinine- an# ("ina/ )i) )$o(/# 3e o3taine# in a// patient) p"e)enting !it$ $ pe"ten)i%e c"i)e)+*A A pe"ip$e"a/ 3/oo# )mea" )$o(/# 3e o3taine# to #etect t$e p"e)ence o1 a mic"oangiopat$ic $emo/ tic anemia+ In a##ition- a c$e)t "a#iog"ap$- EC'an# $ea# CT a"e ()e1(/ in patient) !it$ e%i#ence o1 )$o"tne)) o1 3"eat$- c$e)t pain- o" ne("o/ogic c$ange)- "e)pecti%e/ + An ec$oca"#iog"am )$o(/# 3e o3taine# to a))e)) /e1t %ent"ic(/a" 1(nction an# e%i#ence o1 %ent"ic(/a" $ pe"t"op$ + In man in)tance)- t$e)e te)t) a"e pe"1o"me# )im(/taneo()/ !it$ t$e initiation o1 anti$ pe"ten)i%e t$e"ap + P"e%io() SectionNe2t Section

Therape tic Approach

Patient) !it$ $ pe"ten)i%e eme"gencie) "e8(i"e imme#iate cont"o/ o1 t$e BP to te"minate ongoing en#5o"gan #amage- )ut not to return B* to normal le(el +.;<=*.*;;B In patient) !it$ $ pe"ten)i%e ("gencie)- BP i) /o!e"e# g"a#(a// o%e" a pe"io# o1 .< to <@ $- ()(a// !it$ o"a/ me#ication+ T$e e/e%ate# BP in patient) !it$ $ pe"ten)i%e eme"gencie) )$o(/# 3e t"eate# in a cont"o//e# 1a)$ion in an ICU+ Int"a5a"te"ia/ BP monito"ing i) e))entia/ in a// patient) !it$ $ pe"ten)i%e eme"gencie)+ T$e ()e o1 )(3/ing(a/ ni1e#ipine m()t 3e )t"ong/ con#emne#F t$i) agent ma "e)(/t in a p"ecipito() an# (ncont"o//e# 1a// in BP+ 'i%en t$e )e"io()ne)) o1 t$e "epo"te# a#%e")e e%ent) an# t$e /ack o1 an c/inica/ #oc(mentation atte)ting to a 3ene1it- t$e ()e o1 ni1e#ipine cap)(/e) 1o" $ pe"ten)i%e eme"gencie) an# Cp)e(#oeme"gencie)D )$o(/# 3e a3an#one#+;?;@;A<B<*<.<;<<<=<> Simi/a"/ - IV $ #"a/a4ine ma "e)(/t in )e%e"e- p"o/onge#- an# (ncont"o//e# $ poten)ion- an# it i) t$e"e1o"e not "ecommence#+ Rapi# an# (ncont"o//e# "e#(ction o1 BP ma "e)(/t in ce"e3"a/- m oca"#ia/- an# "ena/ i)c$emiaHin1a"ction+.A;B;? T$e imme#iate goa/ o1 IV t$e"ap i) to "e#(ce t$e #ia)to/ic BP 3 *B to *=J- o" to a3o(t **B mm Hg+ In patient) !it$ ac(te ao"tic #i))ection- t$i) goa/ )$o(/# 3e ac$ie%e# !it$in = to *B min+ In t$e ot$e" patient)- t$i) en# point )$o(/# 3e ac$ie%e# !it$in ;B to >B min+.@ Once t$e en# point) o1 t$e"ap $a%e 3een "eac$e#- t$e patient can 3e )ta"te# on a "egimen o1 o"a/ maintenance t$e"ap + In p"egnanc 5"e/ate# $ pe"ten)ion- IV #"(g t$e"ap i) "e)e"%e# 1o" t$o)e patient) !it$ pe")i)tent ) )to/ic BP) G *@B mm Hg o" pe")i)tent #ia)to/ic BP) G **B mm Hg 6*B= mm Hg in )ome in)tit(tion)7+<? P"io" to #e/i%e" - it i) #e)i"a3/e to maintain t$e #ia)to/ic BP G AB mm Hg+ T$i) p"e))("e a//o!) 1o" a#e8(ate (te"op/acenta/ pe"1()ion+ I1 #ia)to/ic BP #ec"ea)e) to K AB mm Hg- #ec"ea)e# (te"op/acenta/ pe"1()ion ma p"ecipitate ac(te 1eta/ #i)t"e))

p"og"e))ing to an in5(te"o #eat$ o" to pe"inata/ a)p$ 2ia+ A1te" #e/i%e" - an ac(te- "api# #ec"ea)e in BP ()(a// mean) )(3)tantia/ 3/oo# /o)) an# not a c("e o1 t$e #i)ea)e p"oce))+ It )$o(/# 3e emp$a)i4e# t$at on/ patient) !it$ $ pe"ten)i%e c"i)e)Heme"gencie) 6Ta3/e .7 "e8(i"e imme#iate "e#(ction o1 a ma"ke#/ e/e%ate# BP+ In a// ot$e" patient)- t$e e/e%ate# BP can 3e /o!e"e# )/o!/ ()ing o"a/ agent)+ In patient) !$o $a%e )(11e"e# a maIo" ce"e3"o%a)c(/a" e%ent- t$e BP )$o(/# not 3e /o!e"e#- e2cept in e2ceptiona/ ci"c(m)tance) 6)ee 3e/o!7+

Pharmacologic Management
A g"o!ing n(m3e" o1 agent) a"e a%ai/a3/e 1o" management o1 $ pe"ten)i%e c"i)e)+ T$e app"op"iate t$e"ape(tic app"oac$ !i// #epen# on t$e c/inica/ p"e)entation o1 t$e patient+ Ho!e%e"- agent) t$at can 3e a#mini)te"e# IV t$at a"e "api# acting- a"e ea)i/ tit"ata3/e- an# $a%e a )$o"t $a/15/i1e a"e "ecommen#e# 6Ta3/e ; 7+ P"e%io() SectionNe2t Section

Antihypertensive Dr gs "sed in Hypertensive Crises #$isted Alphabetically%

Clonidine
C/oni#ine i) a%ai/a3/e a) an o"a/ an# t"an)#e"ma/ 1o"m(/ation+ O"a/ c/oni#ine 6B+* mg po e%e" .B min7 $a) 3een ()e# 1o" t$e t"eatment o1 $ pe"ten)i%e ("gencie)+<@<A T$e on)et o1 action i) !it$in ;B min to . $- !it$ a #("ation o1 action o1 > to @ $+ In a "an#om- #o(3/e53/in# )t(# - compa"ing t$e e11ect) o1 o"a/ ni1e#ipine %) o"a/ c/oni#ine in =* patient)- c/oni#ine !a) 1o(n# to p"o#(ce a mo"e g"a#(a/ #ec"ea)e in BP t$an ni1e#ipine+<@ Se#ation !a) o3)e"%e# in t$o)e patient) taking c/oni#ine+ T$i) me#ication i) an e2ce//ent c$oice 1o" t$o)e patient) in !$om "api# cont"o/ o1 BP i) not "e8(i"e#+

Dia&o'ide
T$i) #"(g "e/a2e) a"te"io/a" )moot$ m()c/e an# $a) 3een ()e# in t$e t"eatment o1 )e%e"e $ pe"ten)ion+=B 9$en gi%en IV- t$e on)et o1 action i) !it$in * min- !it$ a peak action at *B min- an# a tota/ #("ation o1 action "anging 1"om ; to *@ $+=* T$e #o)e o1 a#mini)t"ation o1 #ia4o2i#e i) a mini3o/() o1 * to ; mgHkg- to ma2im(m o1 *=B mg 6)ing/e #o)e7 inIecte# o%e" *B to *= min+*; I1 t$e "e)pon)e i) ina#e8(ate- "epeate# #o)e) at *B5 to *=5min inte"%a/) ma 3e gi%en+ Dia4o2i#e $a) )igni1icant )i#e e11ect)+ Sa/t an# !ate" "etention a"e common/ )eenan# $ pe"g/ cemia an# $ pe"("icemia ma a/)o occ("+

Enalaprilat
T$e ()e o1 angioten)in5con%e"ting en4 me 6ACE7 in$i3ito") 1o" t$e t"eatment o1 $ pe"ten)i%e c"i)e) $a) 3een )t(#ie# o%e" t$e /a)t . #eca#e)+<.=.=;=<== A) angioten)in II $a) a pat$ogenetic "o/e in t$e #e%e/opment o1 t$e ma/ignant p$a)e o1 $ pe"ten)ion- ACE in$i3ito") ma $a%e an impo"tant "o/e in t$e t"eatment o1 t$e)e patient)+.=.> 9$i/e )(3/ing(a/ captop"i/ $a) 3een ()e# in t$e t"eatment o1 $ pe"ten)i%e c"i)e)- ena/ap"i/at- !$ic$ i) a%ai/a3/e in an IV 1o"m(/ation-

$a) gaine# pop(/a"it 1o" ()e in )ome $ pe"ten)i%e eme"gencie)+=;===>=?=@=A Ena/ap"i/at $a) an on)et o1 action !it$in *= min- !it$ a #("ation o1 action o1 *. to .< $+ Hi")c$/ an# co//eag(e)=? $a%e #emon)t"ate# t$at t$e #eg"ee o1 t$e BP "e#(ction !it$ IV ena/ap"i/at i) co""e/ate# !it$ t$e p"et"eatment concent"ation o1 angioten)in II an# p/a)ma "enin acti%it + No a#%e")e )i#e e11ect) o" ) mptomatic $ poten)ion $a) 3een "epo"te# !it$ IV ena/ap"i/atF $o!e%e"- ACE in$i3ito") a"e cont"ain#icate# in p"egnanc +=;=?

Esmolol
E)mo/o/ i) a ca"#io)e/ecti%e- :5a#"ene"gic 3/ocking agent t$at $a) an e2t"eme/ )$o"t #("ation o1 action+>B>*>. T$e meta3o/i)m o1 e)mo/o/ i) %ia "api# $ #"o/ )i) 3 RBC) an# i) not #epen#ent on "ena/ o" $epatic 1(nction+ T$e on)et o1 action i) !it$in >B )- !it$ a #("ation o1 action o1 *B to .B min+>B>*>. T$e p$a"macokinetic p"ope"tie) o1 e)mo/o/- make it t$e Ci#ea/ :5 a#"ene"gic 3/ocke"D 1o" ()e in c"itica// i// patient)+ T$i) agent i) a%ai/a3/e 1o" IV ()e- 3ot$ a) a 3o/() an# a) an in1()ion+ It i) o1 pa"tic(/a" %a/(e 1o" )ome )(p"a%ent"ic(/a" # )"$ t$mia)an# "ecent/ $a) 3een ()e# in patient) !it$ $ pe"ten)i%e c"i)e) an# po)tope"ati%e $ pe"ten)ion+>;><>=>>>?>@>A E)mo/o/ $a) p"o%en )a1e in patient) !it$ ac(te m oca"#ia/ in1a"ctione%en t$o)e !$o $a%e "e/ati%e cont"ain#ication) to :53/ocke")+?B T$e "ecommen#e# initia/ #o)e i) B+= mgHkg 1o//o!e# 3 an in1()ion at .= to ;BB LgHkgHmin+

(enoldopam
T$i) agent $a) "ecent/ 3een app"o%e# 1o" t$e management o1 ac(te $ pe"ten)ion in t$e Unite# State)+ It i) a #opamine 6DA7* agoni)t t$at i) )$o"t acting an# $a) t$e a#%antage) o1 inc"ea)ing "ena/ 3/oo# 1/o! an# )o#i(m e2c"etion+ Feno/#opam $a) "e/ati%e/ (ni8(e action) an# "ep"e)ent) a ne! catego" o1 anti$ pe"ten)i%e me#ication+ 9$i/e t$e )t"(ct("e o1 1eno/#opam i) 3a)e# on DA- t$e 1o"me" i) $ig$/ )peci1ic 1o" on/ DA* "ecepto") an# i) *B time) mo"e potent t$an DA a) a "ena/ %a)o#i/ato"+?* T$e )peci1ic "ecepto" acti%ation i) o1 pa"amo(nt %a/(e in t$e #i11e"entiation o1 action) 3et!een DA an# 1eno/#opam+ A) 1eno/#opam inte"act) on/ !it$ DA* "ecepto")- it) ()e i) not a))ociate# !it$ t$e a#%e")e e11ect) "e/ate# to M*5 an# :*5acti%ation+ Feno/#opam acti%ate) #opamine"gic "ecepto") on t$e p"o2ima/ an# #i)ta/ t(3(/e)- in$i3it) )o#i(m "ea3)o"ption- an# "e)(/t) in #i("e)i) an# nat"i("e)i)+?.?; Feno/#opam i) "api#/ an# e2ten)i%e/ meta3o/i4e# 3 conI(gation in t$e /i%e"- !it$o(t pa"ticipation o1 c toc$"ome P5 <=B en4 me)+ T$e p"incipa/ "o(te) o1 conI(gation a"e met$ /ation- g/(c("oni#ation- an# )(/1ation+ On/ <J o1 t$e a#mini)te"e# #o)e i) e2c"ete# (nc$ange#+ Anima/ #ata in#icate t$at t$e meta3o/ite) a"e inacti%e+?< T$e on)et o1 action i) !it$in = min- !it$ t$e ma2ima/ "e)pon)e 3eing ac$ie%e# 3 *= min+?=?>?? T$e #("ation o1 action i) 3et!een ;B to >B min- !it$ t$e p"e))("e g"a#(a// "et("ning to p"et"eatment %a/(e) !it$o(t "e3o(n# once t$e in1()ion i) )toppe#+?=?>?? No a#%e")e e11ect) $a%e 3een "epo"te#+?= T$e #o)e "ate o1 1eno/#opam m()t 3e in#i%i#(a/i4e# acco"#ing to 3o# !eig$t an# acco"#ing to t$e #e)i"e# "api#it an# e2tent o1 t$e p$a"maco# namic e11ect+ An initia/ )ta"ting #o)age o1 B+* LgHkgHmin i) "ecommen#e#+ Feno/#opam $a) 3een (n#e" c/inica/ in%e)tigation )ince *A@*- an# $a) 3een a#mini)te"e# IV to G *-BBB patient)+ In a p"o)pecti%e- "an#omi4e#- open5/a3e/- m(/ticente" c/inica/ t"ia/Panacek an# co!o"ke")?@ compa"e# 1eno/#opam !it$ nit"op"())i#e in t$e t"eatment o1 ac(te $ pe"ten)ion- conc/(#ing t$at 3ot$ agent) $a# e8(i%a/ent e11icac + Ho!e%e"- 1eno/#opam $a) 3een #emon)t"ate# to imp"o%e c"eatinine c/ea"ance- ("ine 1/o! "ate)- an# )o#i(m e2c"etion in )e%e"e/ $ pe"ten)i%e patient) !it$ 3ot$ no"ma/ an# impai"e# "ena/ 1(nction- !$e"ea) t$e)e

pa"amete") 1a// in patient) t"eate# !it$ nit"op"())i#e+?;?A@B Feno/#opam ma t$e"e1o"e 3e t$e #"(g o1 c$oice in )e%e"e/ $ pe"ten)i%e patient) !it$ impai"e# "ena/ 1(nction+@*

$abetalol
La3eta/o/ i) a com3ine# 3/ocke" o1 M5 an# :5a#"ene"gic "ecepto")+ 'i%en IV- t$e MH:53/ocking "atio i) *N?+@. T$e maIo"it o1 t$e #"(g i) meta3o/i4e# 3 t$e /i%e" to 1o"m an inacti%e g/(c("oni#e conI(gate+@; T$e $ poten)i%e e11ect o1 /a3eta/o/ 3egin) !it$in . to = min a1te" an IV #o)e- "eac$e) it) peak at = to *= min- an# pe")i)t) 1o" a3o(t . to < $+@;@< Hea"t "ate i) maintaine# o" )/ig$t/ "e#(ce# #(e to it) :53/ocking e11ect+ Un/ike p("e :53/ocke")- !$ic$ #ec"ea)e ca"#iac o(tp(t- /a3eta/o/ maintain) ca"#iac o(tp(t+@= La3eta/o/ "e#(ce) pe"ip$e"a/ %a)c(/a" "e)i)tance !it$o(t "e#(cing pe"ip$e"a/ 3/oo# 1/o!F ce"e3"a/- "ena/- an# co"ona" 3/oo# 1/o! a"e maintaine#+@=@>@?@@ Litt/e p/acenta/ t"an)1e" occ(")- main/ #(e to t$e neg/igi3/e /ipi# )o/(3i/it o1 t$e #"(g+@= La3eta/o/ $a) 3een )$o!n to 3e e11ecti%e an# )a1e in t$e management o1 $ pe"ten)i%e eme"gencie)- a) !e// a) patient) !it$ ac(te m oca"#ia/ in1a"ction !it$ ) )temic $ pe"ten)ion+@=@?@A A /oa#ing #o)e o1 .B mg i) "ecommen#e#- 1o//o!e# 3 "epeate# inc"ementa/ #o)e) o1 .B to @B mg gi%en at *B5min inte"%a/) (nti/ t$e t$e"ape(tic goa/ i) ac$ie%e#+ A/te"nati%e/ - a1te" t$e initia/ /oa#ing #o)e- an in1()ion commencing at * to . mgHmin an# tit"ate# (p to (nti/ t$e #e)i"e# $ poten)i%e e11ect i) ac$ie%e# ma 3e pa"tic(/a"/ e11ecti%e+ Once t$e ta"get BP $a) 3een ac$ie%e#- o"a/ t$e"ap can 3e initiate#+ La"ge- 3o/() inIection) o1 * to . mgHkg $a%e 3een "epo"te# to p"o#(ce p"ecipito() 1a//) in BP an# )$o(/# t$e"e1o"e 3e a%oi#e#+AB

)icardipine
O%e" t$e /a)t = ea")- an IV 1o"m o1 nica"#ipine $a) 3een a%ai/a3/e an# app"o%e# in t$e Unite# State) 1o" t$e t"eatment o1 )e%e"e $ pe"ten)ion+ Nica"#ipine i) a #i$ #"op "i#ine5 #e"i%ati%e ca/ci(m c$anne/ 3/ocke"+ It #i11e") 1"om ni1e#ipine 3 t$e a##ition o1 a te"tia" amine )t"(ct("e in t$e e)te" )i#e c$ain 1"om po)ition t$"ee o1 t$e $ #"op "i#ine "ing an# t$e mo%ement o1 t$e nit"o g"o(p to t$e meta po)ition o1 t$e p$en / "ing+A*A. T$e)e #i11e"ence) make nica"#ipine *BB time) mo"e !ate" )o/(3/e t$an ni1e#ipine- an#- t$e"e1o"e- it can 3e a#mini)te"e# IV- making nica"#ipine a tit"ata3/e IV ca/ci(m c$anne/ 3/ocke"+ T$e on)et o1 action o1 IV nica"#ipine i) 3et!een = to *= min- !it$ a #("ation o1 action o1 < to > $+ Se%e"a/ )t(#ie) $a%e e2amine# t$e ac(te e11ect) o1 nica"#ipine !$en a#mini)te"e# to patient) !it$ )e%e"e $ pe"ten)ion+..@<A;A<A=A>A?A@AA T$e"e $a%e a/)o 3een )e%e"a/ )t(#ie) p(3/i)$e# compa"ing t$e e11ect) o1 nica"#ipine !it$ )o#i(m nit"op"())i#e+ Ha/pe"n an# coa(t$o")A= con#(cte# a m(/ticente"- p"o)pecti%e- "an#omi4e# )t(# compa"ing t$e e11ect o1 t$i) agent !it$ nit"op"())i#e in patient) !it$ )e%e"e po)tope"ati%e $ pe"ten)ion+ T$e)e a(t$o") "epo"te# nica"#ipine to 3e a) e11ecti%e a) )o#i(m nit"op"())i#e+ IV nica"#ipine- $o!e%e"- $a) 3een )$o!n to "e#(ce 3ot$ ca"#iac an# ce"e3"a/ i)c$emia+;@ It) #o)e i) in#epen#ent o1 t$e patientO) !eig$t+ T$e c(""ent "ecommen#e# #o)age 1o" "api# BP cont"o/ i) = mgH$- inc"ea)ing t$e in1()ion "ate 3 .+= mgH$ e%e" = min 6to a ma2im(m o1 *= mgH$7 (nti/ t$e #e)i"e# BP "e#(ction i) ac$ie%e#+

)ifedipine

O"a/H)(3/ing(a/ t$e"ap !it$ )$o"t5acting ni1e#ipine $a) 3een !i#e/ ()e# in t$e management o1 $ pe"ten)i%e eme"gencie)- )e%e"e $ pe"ten)ion a))ociate# !it$ c$"onic "ena/ 1ai/("epe"iope"ati%e $ pe"ten)ion- an# p"egnanc 5in#(ce# $ pe"ten)ion+;A<B<*<.<;*BB*B**B.*B; Ni1e#ipine i) not a3)o"3e# t$"o(g$ t$e 3(cca/ m(co)a- 3(t i) "api#/ a3)o"3e# 1"om t$e 'I t"act a1te" t$e cap)(/e i) 3"oken an# #i))o/%e#+<< Ni1e#ipine ca()e) #i"ect %a)o#i/atation o1 a"te"io/e)"e#(cing pe"ip$e"a/ %a)c(/a" "e)i)tance+ A )igni1icant #ec"ea)e in BP i) o3)e"%e# = to *B min a1te" ni1e#ipine a#mini)t"ation- !it$ a peak e11ect at 3et!een ;B to >B min an# a #("ation o1 action o1 a3o(t > $+*BB T$i) 1o"m o1 t$e"ap - $o!e%e"- i) not C3enign+D;?;@<= A) mentione# ea"/ie"- )(##en "e#(ction) in BP accompan ing t$e a#mini)t"ation o1 ni1e#ipine ma p"ecipitate ce"e3"a/- "ena/- an# m oca"#ia/ i)c$emic e%ent) t$at $a%e 3een a))ociate# !it$ 1ata/ o(tcome)+;? E/#e"/ $ pe"ten)i%e patient) !it$ (n#e"/ ing )t"(ct("a/ %a)c(/a" #i)ea)e an# ta"get o"gan impai"ment ten# to 3e mo"e %(/ne"a3/e to t$e "api# an# (ncont"o//e# "e#(ction in a"te"ia/ p"e))("e+;? Beca()e t$e $ poten)i%e e11ect) o1 ni1e#ipine cannot 3e c/o)e/ "eg(/ate#- t$i) #"(g hould not )e u ed 1o" BP cont"o/ in patient) !it$ $ pe"ten)i%e c"i)e)+

)itropr sside
So#i(m nit"op"())i#e i) an a"te"ia/ an# %eno() %a)o#i/ato" t$at #ec"ea)e) 3ot$ a1te"/oa# an# p"e/oa#+*B<*B=*B>*B?*B@ T$i) #"(g "eact) !it$ c )teine to 1o"m nit"oc )teine+ T$e /ate" acti%ate) g(an /ate c c/a)e- !$ic$- in t("n- )tim(/ate) t$e 1o"mation o1 c c/ic g(ano)ine monop$o)p$ate t$at "e/a2e) )moot$ m()c/e+ 9$en ()ing t$i) agent- ce"e3"a/ 3/oo# 1/o! 6CBF7 ma #ec"ea)e in a #o)e5#epen#ent manne"+ F("t$e"mo"e- 3ot$ c/inica/ an# e2pe"imenta/ )t(#ie) #emon)t"ate t$at nitropru ide increa e intracranial pre ure+*BA**B*****. Nit"op"())i#e i) a %e" potent agent+ T$e on)et o1 action o1 t$i) #"(g i) !it$in )econ#)- !it$ a #("ation o1 action o1 * to . min an# a p/a)ma $a/15/i1e o1 ; to < min+*B<*B=*B>*B?*B@**; I1 t$e in1()ion i) )toppe# a3"(pt/ - t$e BP 3egin) to "i)e imme#iate/ an# "et("n) to t$e p"et"eatment /e%e/ !it$in * to *B min+ In patient) !it$ co"ona" a"te" #i)ea)e- a )igni1icant "e#(ction in "egiona/ 3/oo# 1/o! 6co"ona" )tea/7 can occ("+**< In a /a"ge "an#omi4e#p/ace3o5cont"o//e# t"ia/- nit"op"())i#e !a) )$o!n to inc"ea)e mo"ta/it !$en in1()e# in t$e ea"/ $o(") a1te" ac(te m oca"#ia/ in1a"ction 6mo"ta/it at *; !eek)- .<+.J %) *.+?J7+**= So#i(m nit"op"())i#e i) meta3o/i4e# into c anogen- !$ic$ i) con%e"te# into t$ioc anate 3 t$e en4 me t$io)(/1ate )(/1("t"an)1e"a)e+*B? Nit"op"())i#e contain) <<J c ani#e 3 !eig$t+ C ani#e i) "e/ea)e# nonen4 matica// 1"om nit"op"())i#e- t$e amo(nt gene"ate# 3eing #epen#ent on t$e #o)e o1 nit"op"())i#e a#mini)te"e#+ C ani#e i) meta3o/i4e# in t$e /i%e" to t$ioc anate+ T$io)(/1ate i) "e8(i"e# 1o" t$i) "eaction+*B?**> T$ioc anate i) *BB time) /e)) to2ic t$an c ani#e+ T$e t$ioc anate gene"ate# i) e2c"ete# /a"ge/ t$"o(g$ t$e ki#ne )+ C ani#e "emo%a/ t$e"e1o"e "e8(i"e) a#e8(ate /i%e" 1(nction- a#e8(ate "ena/ 1(nction- an# a#e8(ate 3ioa%ai/a3i/it o1 t$io)(/1ate+ So#i(m nit"op"())i#e $a) 3een #emon)t"ate# to ca()e c toto2icit t$"o(g$ t$e "e/ea)e o1 nit"ic o2i#e- !it$ $ #"o2 / "a#ica/ an# pe"o2 nit"ite gene"ation /ea#ing to /ipi# pe"o2i#ation+**?**@ Nit"op"())i#e ma a/)o ca()e c toto2icit #(e to t$e "e/ea)e o1 c ani#e!it$ inte"1e"ence o1 ce//(/a" "e)pi"ation+**A*.B Ra($a/a an# co//eag(e)*.* #emon)t"ate# /ipi# pe"o2i#ation in t$e )(3)tantia nig"a o1 "at) a1te" t$e a#mini)t"ation o1 nit"op"())i#e+ Lipi# pe"o2i#ation $a) a/)o 3een #emon)t"ate# in $epatoc te)+**A In a##ition- nit"op"())i#e ca()e) concent"ation an# time5#epen#ent ototo2icit +*..*.; C ani#e to2icit $a) 3een #oc(mente# to "e)(/t in C(ne2p/aine# ca"#iac a""e)t-D coma- encep$a/opat$ - con%(/)ion)- an# i""e%e")i3/e

1oca/ ne("o/ogic a3no"ma/itie)+*B@*.< T$e c(""ent met$o#) o1 monito"ing 1o" c ani#e to2icit a"e in)en)iti%e+ Meta3o/ic aci#o)i) i) ()(a// a p"ete"mina/ e%ent+ In a##ition- a "i)e in )e"(m t$ioc anate /e%e/) i) a /ate e%ent an# not #i"ect/ "e/ate# to c ani#e to2icit + RBC c ani#e concent"ation) 6a/t$o(g$ not !i#e/ a%ai/a3/e7 ma 3e a mo"e "e/ia3/e met$o# o1 monito"ing 1o" c ani#e to2icit +*B? An RBC c ani#e concent"ation G <B nmo/HmL "e)(/t) in #etecta3/e meta3o/ic c$ange)+ Le%e/) G .BB nmo/HL a"e a))ociate# !it$ )e%e"e c/inica/ ) mptom)- an# /e%e/) G <BB nmo/HmL a"e con)i#e"e# /et$a/+*B? Data )(gge)t t$at nit"op"())i#e in1()ion "ate) G < LgHkgHmin 1o" a) /itt/e a) . to ; $ ma /ea# to c ani#e /e%e/) t$at a"e in t$e to2ic "ange+*B? T$e "ecommen#e# #o)e) o1 nit"op"())i#e o1 (p to *B LgHkgHmin "e)(/t in c ani#e 1o"mation at a 1a" g"eate" "ate t$an $(man 3eing) can #eto2i1 + Con)i#e"ing t$e potentia/ 1o" )e%e"e to2icit !it$ nit"op"())i#e- t$i) #"(g )$o(/# 3e ()e# on/ !$en ot$e" IV anti$ pe"ten)i%e agent) a"e not a%ai/a3/e- an# t$en on/ in patient) !it$ no"ma/ "ena/ an# $epatic 1(nction+*B@ T$e #("ation o1 t"eatment )$o(/# 3e a) )$o"t a) po))i3/ean# t$e in1()ion "ate )$o(/# not 3e G . LgHkgHmin+ An in1()ion o1 t$io)(/1ate )$o(/# 3e ()e# in patient) "ecei%ing $ig$e" #o)age) 6< to *B LgHkgHmin7 o1 nit"op"())i#e+**> It $a) a/)o 3een #emon)t"ate# t$at $ #"o2oco3a/amin 6%itamin *.a7 i) )a1e an# e11ecti%e in p"e%enting an# t"eating c ani#e to2icit a))ociate# !it$ t$e ()e o1 nit"op"())i#e+ T$i) ma 3e gi%en a) a contin(o() in1()ion at a "ate o1 .= mgH$+ H #"o2oco3a/amin i) (n)ta3/e an# )$o(/# 3e )to"e# #" an# p"otecte# 1"om /ig$t+ C anoco3a/amin 6B*.7- $o!e%e"- i) ine11ecti%e a) an anti#ote an# i) not capa3/e o1 p"e%enting c ani#e to2icit +

Phentolamine
P$ento/amine i) an M5a#"ene"gic 3/ocking agent t$at i) 1"e8(ent/ ()e# 1o" management o1 catec$o/amine5in#(ce# $ pe"ten)i%e c"i)e) 6ie- p$eoc$"omoc toma7+;?*@;.;;;> T$i) me#ication i) gi%en IV in *5 to =5mg 3o/()e)+ T$e e11ect i) imme#iate an# ma /a)t (p to *= min+ Contin(o() IV in1()ion) $a%e a/)o 3een ()e# !it$ %a"ia3/e e11ect)+ T$i) agent ma ca()e tac$ # )"$ t$mia) o" angina+ Once t$e initia/ BP i) (n#e" cont"o/- o"a/ p$eno2 3en4amine- a /ong5acting M5a#"ene"gic 3/ocking agent- ma 3e gi%en+

Trimethaphan Camsylate
T"imet$ap$an cam) /ate i) a non#epo/a"i4ing gang/ionic 3/ocking agent+ It 3/ock) t$e t"an)mi))ion o1 imp(/)e) at t$e ) mpat$ic an# pa"a) mpat$ic gang/ia 3 competing !it$ acet /c$o/ine 1o" c$o/ine"gic "ecepto")+? T$i) acco(nt) 1o" 3ot$ it) e11icac an# it) n(me"o() )i#e e11ect)+ T$e "e#(ction in BP o3)e"%e# !it$ t$i) agent i) ca()e# 3 t$e a#"ene"gic 3/ocka#e "e)(/ting in %a)o#i/atation+ T$e on)et o1 action i) !it$in * to = min- !it$ a #("ation o1 action o1 *B min+ T$e a#mini)t"ation i) 3 con)tant IV in1()ion 6=BB mg i) mi2e# in =BB mL o1 =J #e2t"o)e !ate"7- an# i) gi%en a) initia/ #o)age o1 B+= to * mgHmin+ T$e #o)e i) t$en tit"ate# to ac$ie%e t$e #e)i"e# BP (p to a ma2im(m o1 *= mgHmin+ Tac$ p$ /a2i) i) a common )i#e e11ect !it$ t$i) me#ication+ It ()(a// occ(") !it$in t$e 1i")t . #a ) o1 a#mini)t"ation+

*ther Agents
Nit"og/ ce"in an# $ #"a/a4ine a"e )ometime) ()e# in t$e t"eatment o1 $ pe"ten)i%e c"i)e)- an# nit"og/ ce"in ma p/a a )igni1icant "o/e in t$o)e patient) !it$ ca"#iac i)c$emia+ Ho!e%e"- it i) impo"tant to emp$a)i4e t$at nit"og/ ce"in i) not an e11ecti%e %a)o#i/ato"+*.= Nit"og/ ce"in i) a potent %eno#i/ato"- an# on/ at $ig$ #o)e) a11ect) a"te"ia/ tone+ Nit"og/ ce"in "e#(ce) BP 3

"e#(cing p"e/oa# an# ca"#iac o(tp(t- (n#e)i"a3/e e11ect) in patient) !it$ comp"omi)e# ce"e3"a/ an# "ena/ pe"1()ion+ In a##ition- it "e8(i"e) )pecia/ t(3ing 1o" a#mini)t"ation+ H #"a/a4ine $a) 3een ()e# a) an anti$ pe"ten)i%e agent 1o" G <B ea")+ Fo//o!ing an IM o" IV #o)e- t$e"e i) an initia/ /atent pe"io# o1 = to *= min 1o//o!e# 3 a p"og"e))i%e 6o1ten p"ecipito()7 1a// in BP /a)ting 1o" (p to *. $+*.>*.? A/t$o(g$ t$e ci"c(/ating $a/15/i1e o1 t$e #"(g i) a3o(t ; $- t$e $a/15time o1 it) e11ect on BP i) a3o(t *BB $+*.@ H #"a/a4ine $a) 3een #emon)t"ate# to 3in# to t$e !a//) o1 m()c(/a" a"te"ie)+*.A*;B*;* T$i) ma e2p/ain t$e p"o/onge# p$a"maco/ogic e11ect o1 t$e #"(g+ Beca()e o1 t$e p"o/onge# an# (np"e#icta3/e anti$ pe"ten)i%e e11ect) o1 t$e #"(g- an# t$e ina3i/it to e11ecti%e/ tit"ate it) $ poten)i%e e11ect- $ #"a/a4ine )$o(/# 3e a%oi#e# in t$e management o1 $ pe"ten)i%e eme"gencie)+ Ot$e" "egimen) (ti/i4ing me#ication) )(c$ a) "e)e"pine- met$ /#opa- o" g(anet$i#ine $a%e /a"ge/ 3een "ep/ace# 3 t$e agent) #e)c"i3e# a3o%e+ P"e%io() SectionNe2t Section

Treatment in +pecial +it ations

Ac te Aortic Dissection
IV anti$ pe"ten)i%e t"eatment )$o(/# 3e )ta"te# in t$e eme"genc #epa"tment in a// patient) 6e2cept patient) !it$ $ poten)ion7 a) )oon a) t$e #iagno)i) o1 ac(te ao"tic #i))ection i) )()pecte# 6Ta3/e < 7+*;* T$e)e patient) m()t 3e a#mitte# to an ICU a) an eme"genc + Va)c(/a" p"e))("e)- ("ine o(tp(t- menta/ )tat()- an# ne("o/ogic )ign) )$o(/# 3e c/o)e/ monito"e# 1o" an #ete"io"ation o!ing to comp/ication)+ T$e aim o1 anti$ pe"ten)i%e t$e"ap i) to /e))en t$e p(/)ati/e /oa# o" ao"tic )t"e)) 3 /o!e"ing t$e BP+ Re#(cing t$e 1o"ce o1 /e1t %ent"ic(/a" cont"action) an#- con)e8(ent/ - t$e "ate o1 "i)e o1 ao"tic p"e))("e "eta"#) t$e p"opagation o1 t$e #i))ection an# ao"tic "(pt("e+ T$e com3ination o1 a %a)o#i/ato" an# a :53/ocke" i) t$e )tan#a"# anti$ pe"ten)i%e "egimen ()e# in t$e)e patient)F a %a)o#i/ato" a/one ma ca()e an inc"ea)e in %e/ocit o1 %ent"ic(/a" cont"action an# /ea# to p"opagation o1 #i))ection+ E)mo/o/ i) t$e :5a#"ene"gic antagoni)t o1 c$oice+*;. Metop"o/o/ i) a )(ita3/e a/te"nati%e+*;; 9$i/e )o#i(m nit"op"())i#e $a) t"a#itiona// 3een ()e# in patient) !it$ ao"tic #i))ection- nica"#ipine o" 1eno/#opam i) a /e))5to2ic a/te"nati%e+*;;*;< La3eta/o/- an M5 an# :5a#"ene"gic antagoni)t- i) an a/te"nati%e to t$e com3ination o1 nit"op"())i#e an# :53/ocke"+*;= T"imet$ap$an- a gang/ionic 3/ocke" a) !e// a) #i"ect %a)o#i/ato"- can 3e ()e# !$en )o#i(m nit"op"())i#e i) ine11ecti%e o" poo"/ to/e"ate#- o" !$en t$e ()e o1 :53/ocke") i) a "e/ati%e cont"ain#ication #(e to p"ee2i)ting con#ition) )(c$ a) COPD- 3"a# ca"#ia- o" conge)ti%e $ea"t 1ai/("e+ An a#%antage o%e" )o#i(m nit"op"())i#e i) t$at it "e#(ce) 3ot$ a"te"ia/ p"e))("e an# it) "ate o1 inc"ea)e- an# t$e"e1o"e it #oe) not "e8(i"e conc(""ent ()e o1 :53/ocke")+ Ho!e%e"- it i) /e)) p"e#icta3/e t$an )o#i(m nit"op"())i#e an# $a) )i#e e11ect) o1 tac$ p$ /a2i)- )e%e"e $ poten)ion- ("ina" "etention- an# i/e()+ Ca"#io%a)c(/a" )("gica/ con)(/tation i) "e8(i"e# in a// patient) !it$ )()pecte# ao"tic #i))ection)+ S("ge" i) in#icate# 1o" a// #i))ection) in%o/%ing t$e a)cen#ing ao"ta 6t pe A #i))ection7- !it$ t$e e2ception o1 on/ a 1e! patient) !it$ )e"io() a))ociate# con#ition) cont"ain#icating )("ge" +*;>*;? Patient) !it$ $ poten)ion )(gge)ting ao"tic "(pt("e a"e

can#i#ate) 1o" eme"genc )("gica/ "epai"+ Comp/ication) o1 t pe B #i))ection)- )(c$ a) /eakage o1 3/oo# 1"om t$e ao"ta- impai"ment o1 3/oo# 1/o! to an o"gan o" /im3- o" pe")i)tent pain #e)pite an a#e8(ate me#ica/ "egimen a"e 3e)t t"eate# 3 )("ge" + Po(nge" patient) !it$ Ma"1anO) ) n#"ome ma 3ene1it 1"om )("ge" in t$e )(3ac(te p$a)e an# a%oi# "(pt("e o1 a "e)i#(a/ )acc(/a" ane(" )m in t$e 1(t("e+ Patient) !it$ (ncomp/icate# #i)ta/ #i))ection) a"e 3e)t manage# me#ica// in t$e ac(te p$a)e !it$ anti$ pe"ten)i%e t$e"ap - a) )("%i%a/ "ate i) a"o(n# ?=J !$et$e" patient) a"e t"eate# me#ica// o" )("gica// +;* A/)o- t$e)e patient) a"e gene"a// in t$e o/#e" age g"o(p- !it$ a $i)to" o1 ca"#iac- p(/mona" - o" "ena/ #i)ea)e)+

Hypertension After a Cerebrovasc lar Accident

In $ea/t$ $(man)- ce"e3"a/ a(to"eg(/ation maintain) con)tant CBF 3et!een a mean ) )temic a"te"ia/ p"e))("e o1 >B an# *.B mm Hg+ Ho!e%e"- in patient) !it$ c$"onic $ pe"ten)iona(to"eg(/ation i) )et at a $ig$e" /e%e/ 6app"o2imate/ *.B to *>B mm Hg7- p"e)(ma3/ to p"otect t$e 3"ain 1"om t$e e11ect) o1 pe")i)tent $ pe"ten)ion 6Fig *7+.? A1te" a )t"oke- t$e no"ma/ mec$ani)m) o1 ce"e3"a/ a(to"eg(/ation a"e impai"e#+ Pe"1()ion in t$e i)c$emic pen(m3"a 3ecome) p"e))("e #epen#ent+ A "i)e in ) )temic a"te"ia/ p"e))("e ma 3e an a#apti%e "e)pon)e to maintain t$e 3/oo# 1/o! to t$i) %(/ne"a3/e a"ea+ In a )e"ie) o1 ;;< patient) !it$ ac(te )t"oke a#mitte# to t$e $o)pita/- 9a//ace an# Le% *;@ 1o(n# t$at G @BJ $a# e/e%ate# BP on t$e #a o1 a#mi))ion+ T$e BP) 1e// )pontaneo()/ an# g"a#(a// o%e" t$e ne2t *B #a )+ B t$e *Bt$ #a a1te" t$e )t"oke- on/ one t$i"# o1 patient) "emaine# $ pe"ten)i%e+ T$e mec$ani)m) (n#e"/ ing $ pe"ten)ion a1te" a ce"e3"o%a)c(/a" acci#ent $a%e not 3een 1(// e/(ci#ate#+ Acti%ation o1 t$e ) mpat$etic ne"%o() ) )tem ma 3e in%o/%e# a) pa"t o1 a g/o3a/ meta3o/ic "e)pon)e to ce"e3"a/ in1a"ction- ce"e3"a/ $emo""$age- o" a))ociate# e#ema+ T$e"e i) no e%i#ence t$at $ pe"ten)ion $a) a #e/ete"io() e11ect on t$e o(tcome o1 i)c$emic )t"oke) #("ing t$e ac(te p$a)e+;.*;A*<B Lo!e"ing t$e BP in patient) !it$ ce"e3"a/ i)c$emia ma "e#(ce CBF- !$ic$- 3eca()e o1 impai"e# a(to"eg(/ation- ma "e)(/t in 1("t$e" i)c$emic inI(" + T$e common p"actice o1 Cno"ma/i4ingD BP i) potentia// #ange"o()+ 9$en a p"o2ima/ a"te"ia/ o3)t"(ction "e)(/t) in a mi/# )t"oke- a 1a// in BP ma "e)(/t in 1("t$e" in1a"ction in%o/%ing t$e enti"e te""ito" o1 t$at a"te" + T$e c(""ent "ecommen#ation) o1 t$e Ame"ican Hea"t A))ociation i) t$at $ pe"ten)ion in t$e )etting o1 ac(te i)c$emic )t"oke )$o(/# 3e t"eate# on/ C"a"e/ an# ca(tio()/ +D*<**<. It i) gene"a// "ecommen#e# t$at anti$ pe"ten)i%e t$e"ap 3e "e)e"%e# 1o" patient) !it$ a #ia)to/ic p"e))("e G *.B to *;B mm Hg- aiming to "e#(ce t$e p"e))("e 3 no mo"e t$an an a"3it"a" 1ig("e o1 .BJ in t$e 1i")t .< $+;.*;A*<B*<; In patient) !it$ int"ace"e3"a/ $emo""$age- t$e %a/(e o1 ea"/ anti$ pe"ten)i%e t$e"ap in p"e%enting "e3/ee#ing o" "e#(cing %a)ogenic e#ema $a) not 3een #emon)t"ate#+ Ho!e%e"!it$ "a#io/ogic e%i#ence o1 a maIo" int"ace"e3"a/ 3/ee#- ca(tio() /o!e"ing o1 a ) )to/ic BP G .BB mm Hg o" a #ia)to/ic BP G *.B mm Hg i) gene"a// )(gge)te#+*;A*<B*<< T$i) "ecommen#ation i) )(ppo"te# 3 a "ecent )t(# t$at #emon)t"ate# t$at "api# #ec/ine in BP !it$in t$e 1i")t .< $ a1te" an int"ace"e3"a/ $emo""$age !a) a))ociate# !it$ inc"ea)e# mo"ta/it +*<= In t$i) )t(# - t$e "ate o1 #ec/ine in BP !a) in#epen#ent/ a))ociate# !it$ inc"ea)e# mo"ta/it + T$e e11ect !a) in#epen#ent o1 ot$e" %a"ia3/e) kno!n to co""e/ate !it$ o(tcome a1te" int"ace"e3"a/ $emo""$age- inc/(#ing $ematoma %o/(me- initia/ '/a)go! Coma Sca/e )co"e- an# p"e)ence o1 %ent"ic(/a" 3/oo#+

To o(" kno!/e#ge- t$e"e a"e no #ata "ega"#ing t$e compa"ati%e e11ect) o1 #i11e"ent anti$ pe"ten)i%e #"(g) on CBF in i)c$emic )t"oke+ In o"#e" to p"e%ent a "api# "e#(ction in BP- )$o"t5acting IV agent) a"e p"e1e""e#+ T$e)e )$o(/# 3e a#mini)te"e# in an ICU (n#e" c/o)e BP monito"ing+ 9$i/e nit"op"())i#e i) common/ ()e# in t$i) )it(ation- t$i) #"(g inc"ea)e) int"ace"e3"a/ p"e))("e an# $a) a %e" na""o! t$e"ape(tic in#e2- pa"tic(/a"/ in patient) !it$ "ena/ # )1(nction 6c ani#e poi)oning7+ La3eta/o/ i) an e11ecti%e agentF $o!e%e"- nica"#ipine o" 1eno/#opam i) a )(ita3/e a/te"nati%e+ IV o" o"a/ ACE in$i3ito")- o"a/ o" )(3/ing(a/ ni1e#ipine- an# $ #"a/a4ine )$o(/# 3e a%oi#e# #(e to t$ei" (np"e#icta3/e an# poo"/ tit"ata3/e anti$ pe"ten)i%e e11ect)+

Preeclampsia
A) mentione# p"e%io()/ - t$e p"e)entation o1 a patient !it$ p"egnanc 5in#(ce# $ pe"ten)ion ma "ange 1"om a mi/# to a /i1e5t$"eatening #i)ea)e p"oce))+ T$e p"oce)) can 3e en#e# on/ 3 #e/i%e" + T$e #eci)ion to contin(e o" to #e/i%e" t$e p"egnanc !i// 3e ma#e 3 con)(/tation 3et!een me#ica/ an# o3)tet"ic pe")onne/+ Mo)t p"eec/amptic patient) a"e %a)ocon)t"icte# an# $emoconcent"ate#+ A1te" initia/ t$e"ap %o/(me e2pan)ion an# $emo#i/(tion occ("+ Magne)i(m )(/1ate i) con)i#e"e# t$e )tan#a"# o1 t$e"ap a) a p"op$ /a2i) 1o" )ei4("e acti%it *<>*<?F t$e /oa#ing #o)e i) < to > g in *BB mL #e2t"o)e B+.= )a/ine )o/(tion o%e" *= to .B min+ A con)tant in1()ion o1 * to . gH$ )$o(/# t$en 3e maintaine# #epen#ing on ("ine o(tp(t an# #eep ten#on "e1/e2e) t$at a"e c$ecke# on an $o("/ 3a)i)+ Detai/e# intake an# o(tp(t "eco"#) m()t 3e maintaine#+ Since "ena/ 1(nction i) 1"e8(ent/ impai"e#- an inc"ea)e in tota/ 3o# !ate" can "e)(/t in p(/mona" e#ema+ In "a"e ca)e)- i1 $ ponat"emia i) a//o!e# to occ("- ce"e3"a/ e#ema ma 3e o3)e"%e#+ H #"a/a4ine $a) 3een ()e# t"a#itiona// in t$e t"eatment o1 ec/amp)ia+ Ho!e%e"- once t$e patient i) a#mitte# to an ICU- /a3eta/o/ o" nica"#ipine i) p"e1e""e#+ Bot$ o"a/ an# IV 1o"m(/ation) o1 /a3eta/o/ an# nica"#ipine appea" to 3e )a1e an# e11ecti%e agent) in $ pe"ten)i%e p"egnant patient)+*<@*<A*=B*=**=.

Hypertensive "rgencies and +ympathetic Crises

A3"(pt #i)contin(ation o1 t"eatment !it$ a )$o"t5acting ) mpat$etic 3/ocke" 6)(c$ a) c/oni#ine o" p"op"ano/o/7 can /ea# to )e%e"e $ pe"ten)ion+ Cont"o/ o1 BP can 3e ac$ie%e# in t$i) )etting 3 "ea#mini)t"ation o1 t$e #i)contin(e# #"(g+ S$o(/# e%i#ence o1 p(/mona" e#ema o1 co"ona" i)c$emia 3e p"e)ent- patient) )$o(/# 3e t"eate# a) o(t/ine# in Ta3/e <+ In a##ition to #"(g t$e"ap !it$#"a!a/- inc"ea)e# a#"ene"gic acti%it can /ea# to )e%e"e $ pe"ten)ion in a %a"iet o1 ot$e" c/inica/ )etting)+ T$e)e inc/(#e t$e ()e o1 ) mpat$omimetic #"(g) )(c$ a) cocaine- amp$etamine)- p$enc c/i#ine- o" t$e com3ination o1 a monoamine o2i#a)e in$i3ito" an# t$e inge)tion o1 t "amine5containing 1oo#)- p$eoc$"omoc toma- an# a(tonomic # )1(nction- a) in '(i//ian5Ba""Q ) n#"ome+ T$e ()e o1 :53/ocke") )$o(/# 3e a%oi#e# in t$e)e patient)- )ince in$i3ition o1 :R"ecepto"5 in#(ce# %a)o#i/ation "e)(/t) in (noppo)e# M5a#"ene"gic %a)ocon)t"iction an# a 1("t$e" "i)e in BP+ T$e ()e o1 :53/ocke") $a) 3een #emon)t"ate# to en$ance cocaine5in#(ce# co"ona" %a)ocon)t"iction- inc"ea)e BP- 1ai/ to cont"o/ t$e $ea"t "ate- inc"ea)e t$e /ike/i$oo# o1 )ei4("e)an# #ec"ea)e )("%i%a/+*=;*=<*== A/t$o(g$ )ome patient) $a%e 3een t"eate# !it$ /a3eta/o/ !it$o(t a#%e")e con)e8(ence)- cont"o//e# e2pe"iment) in anima/) an# $(man) #o not )(ppo"t it)

()e+*=>*=? In )t(#ie) o1 cocaine into2ication in anima/)- /a3eta/o/ inc"ea)e# )ei4("e acti%it an# mo"ta/it +*=@*=A F("t$e"mo"e- e2pe"imenta/ )t(#ie) $a%e #emon)t"ate# t$at /a3eta/o/ #oe) not a//e%iate cocaine5in#(ce# co"ona" %a)ocon)t"iction+*>B La3eta/o/ $a) 3een "epo"te# to $a%e a $ pe"ten)i%e "e)pon)e in patient) !it$ p$eoc$"omoc toma+*>* Cont"o/ o1 BP in t$e)e patient) i) 3e)t ac$ie%e# !it$ nica"#ipine- %e"apami/- o" 1eno/#opam+*==*>.*>; P$ento/amine an# nit"op"())i#e a"e a/te"nati%e agent)+*><

Hypertensive Crises in End,+tage -enal Disease

T$e mo)t impo"tant ca"#io%a)c(/a" comp/ication o1 c$"onic "ena/ 1ai/("e i) $ pe"ten)ion+ T$e ca()e o1 $ pe"ten)ion in c$"onic "ena/ 1ai/("e i) an inc"ea)e in e2t"ace//(/a" %o/(me )econ#a" to )o#i(m "etention 3 t$e #i)ea)e# ki#ne - a) !e// a) %a)ocon)t"iction #(e to inc"ea)e# acti%it o1 t$e "enin5angioten)in ) )tem+.= H pe"ten)i%e c"i)e) ma e2ace"3ate "ena/ 1ai/("e an#- t$e"e1o"e- nee# to 3e t"eate# p"ompt/ + IV ca/ci(m c$anne/ 3/ocke") $a%e 3een ()e# 1o" t$e)e patient) !it$ )ome )(cce))+*>= Patient) ma "e8(i"e eme"gent (/t"a1i/t"ation in o"#e" to cont"o/ t$e BP+ Bi/ate"a/ nep$"ectom $a) 3een "epo"te# to Cc("eD ma/ignant $ pe"ten)ion in $emo#ia/ )i) patient)+*>> P"e%io() SectionNe2t Section

Concl sion
T$e ke to t$e )(cce))1(/ management o1 patient) !it$ )e%e"e/ e/e%ate# BP i) to #i11e"entiate $ pe"ten)i%e c"i)e) 1"om $ pe"ten)i%e ("gencie)+ Patient) !it$ $ pe"ten)i%e ("gencie) $a%e )e%e"e $ pe"ten)ion 6#ia)to/ic G **B mm Hg7- 3(t !it$o(t c/inica/ e%i#ence o1 ac(te en#5o"gan #amage+ Rapi# anti$ pe"ten)i%e t$e"ap i) not !a""ante# in t$e)e patient)+ H pe"ten)i%e c"i)e) con)tit(te a #i)tinct g"o(p o1 c/inicopat$o/ogic entitie) a))ociate# !it$ ac(te ta"get o"gan inI(" + T$e)e patient) "e8(i"e imme#iate BP "e#(ction to p"e%ent p"og"e))i%e en#5o"gan #amage+ H pe"ten)ion a))ociate# !it$ ce"e3"a/ in1a"ction o" int"ace"e3"a/ $emo""$age on/ "a"e/ "e8(i"e) t"eatment+ Patient) !it$ $ pe"ten)i%e c"i)e) a"e 3e)t t"eate# in an ICU !it$ tit"ata3/e IV $ poten)i%e agent)+ Se%e"a/ "api#5acting IV anti$ pe"ten)i%e agent) a"e a%ai/a3/e- inc/(#ing /a3eta/o/- e)mo/o/- 1eno/#opam- nica"#ipinean# )o#i(m nit"op"())i#e+ 9$i/e nit"op"())i#e i) common/ ()e# to t"eat )e%e"e $ pe"ten)ionit i) an e2t"eme/ to2ic #"(g t$at )$o(/# 3e ()e# on/ in "a"e ci"c(m)tance)+ P"e%io() SectionNe2t Section Vie! t$i) ta3/eN In t$i) !in#o! In a ne! !in#o! Ta3/e *+ C/a))i1ication o1 P"eec/amp)iaS Vie! t$i) ta3/eN In t$i) !in#o! In a ne! !in#o!

Ta3/e .+ H pe"ten)i%e Eme"gencie)

Vie! /a"ge" %e")ionN In t$i) page In a ne! !in#o!

Do!n/oa# a) Po!e"Point S/i#e

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(ootnotes

A33"e%iation)N ACE T angioten)in5con%e"ting en4 meF CBF T ce"e3"a/ 3/oo# 1/o!F DA T #opamine
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Accepte# Decem3e" ;- *AAA+

Recei%e# ,(/ A- *AAA+

P"e%io() Section

-eferences
1.

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