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Hypertensive

Crises

Ida Bagus N. Mahendra


RSD Mangusada - Badung
Outline of Discussion:
❑ Definition
❑ Epidemiology
❑ Pathogenesis & Pathophysiogy
❑ Diagnostic Work-up
❑ General Principle for Managing
❑ Specific Aspect of Anti-HTN
❑ Management of Specific Types
TOPICS:
❑ Definition
❑ Epidemiology
❑ Pathogenesis & Pathophysiogy
❑ Diagnostic Work-up
❑ General Principle for Managing
❑ Specific Aspect of Anti-HTN
❑ Management of Specific Types
Definition
Hypertensive Crises
Severe elevations in BP
(>180/120 mm Hg)
Need immediate treatment

Classified as:
Hypertensive Urgencies Hypertensive Emergencies

• Without acute or impending change • Associated with evidence


in target organ damage or dysfunction of new or worsening
(no clinical evidence of acute HMOD) target organ damage
• BP should be reduced within hours (associated with acute HMOD)
ORAL AGENTS • BP should be reduced immediate
PARENTERAL AGENT
HMOD: Hypertension-mediated organ damage
• Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. J Hypertens 2018; 36:1953-2041 and Eur Hear
J 2018;39:3021-3104
• Whelton PK, Carey RM, Aronow WS, Casery DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ ASH/ ASPC/ NMA / PCNA Guideline for the Prevention
Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2018;71:e13-e115
• Kaplan NM, Victor RG,Flynn JT. Hypertensive Emergencies. Kaplan’s Clinical Hypertension 2015. 11th edition.Wolters Kluwer.p.263-274
HMOD
(Hypertension-mediated Organ Damage)
More accurately describes hypertension-induced structural
and/or functional changes in major organs

• HEART
• BRAIN
• RETINA
• KIDNEY
• VASCULATURE

• Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial
hypertension. J Hypertens 2018; 36:1953-2041 and Eur Heart J 2018;39:3021-3104
Pitfalls to Classification
• Slight different BP cut-off
- ESC/ESH Guidelines 2018: SBP ≥180 or DBP ≥110 mm Hg
- ACC/AHA Guidelines 2017: SBP >180 or DBP >120 mm Hg
- Other definition in registries: SBP ≥220 or DBP ≥120 mm Hg

• Emphasis always should be made in determining organ injury:

“The absolute BP level” may not be as important as “The rate BP rise”

Patients with chronic hypertension can often tolerate higher BP levels


than previously normotensive individuals

• Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. J Hypertens 2018;
36:1953-2041 and Eur Heart J 2018;39:3021-3104
• Whelton PK, Carey RM, Aronow WS, Casery DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ ASH/ ASPC/ NMA / PCNA
Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2018;71:e13-e115
Epidemiology
• Among patients with chronic hypertension, 1-2% will experience
hypertensive crises during their lives
→ HT emergencies accounts for approximately 25% of cases

• The annual incidence of HTN emergencies being about 1-2 cases


per 100,000 patients

• Undiagnosed or untreated HTN is the most important risk factor

• In hospital mortality for HTN crises: 4-7%

• Among pts with HTN emergencies, 1 year death rate is more than
79%

• Whelton PK, Carey RM, Aronow WS, Casery DE, Collins KJ, Himmelfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ ASH/
ASPC/ NMA / PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension
2018;71:e13-e115
• Cuspidi C, Pessina AC. Hypertensive Emergencies and Urgencies. In: Mancia G, Grassi G, Redon J. Manual of Hypertension of ESH 2014.
2nd edition. CPC Press.p.367-372
• Pinna G, Pascale C, Fornengo P, Arras S, Piras C, Panzarasa P, et al. Hospital Admissions for Hypertensive Crisis in the Emegency
departements: A Large Multicenter Italian Study. PLOS ONE 2014;9(4):1-6
• Saguner AM, Dur S, Perrig M, Schiemann, Stuck AE, Burgi U, et al. Risk Factor Promoting Hypertensive Crises: Evidence From a Longitudinal
Study. Am J Hypertens 2010;23:775-780
HT Emergencies
HT with retinal hemorrhages and/or papilledema
Cerebrovascular conditions with HT
• Hypertensive encephalopathy
• Atherothrombotic brain infarction with severe hypertension
• Intracerebral hemorrhage
• Subarachnoid hemorrage
• Head trauma
Cardiac conditions with HT
• Acute aortic dissection
• Acute left ventricular failure
• Acute or impending myocardial infarction
• After coronary bypass surgery

• Kaplan NM, Victor RG,Flynn JT. Hypertensive Emergencies. Kaplan’s Clinical Hypertension. 11th edition. 2015.Wolters Kluwer.p.263-274
Renal conditions
• Acute glomerulonephritis
• Renovascular HT
• Collagen vascular diseases
• After kidney transplantation
• Treatment with vascular endothelial growth factor
Excess circulating catecholamines with HT
• Pheochromocytoma crisis
• Food or drug interactions with monoamine oxidase
inhibitors
• Sympathomimetic drug use (cocaine)
• Rebound HT after sudden cessation of antiHT drugs
• Automatic hyperreflexia after spinal cord injury

• Kaplan NM, Victor RG,Flynn JT. Hypertensive Emergencies. Kaplan’s Clinical Hypertension. 11th edition. 2015.Wolters Kluwer.p.263-274
Eclampsia
Surgical conditions
• Severe HT in patients requiring immediate surgery
• Postoperative HT
• Post operative bleeding from vascular suture lines
• Severe body burns
• Severe epistaxis

• Underlying condition clear cause


• Acute sustained elevations in BP are the etiologic factor
• It may be difficult to differentiate wether BP elevation is
the cause or the result of a HT emergency

• Kaplan NM, Victor RG,Flynn JT. Hypertensive Emergencies. Kaplan’s Clinical Hypertension. 11th edition. 2015.Wolters Kluwer.p.263-274
• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J, Tonelli M, Johnson
RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
Precipitating Factors in Hypertensive Crisis
1. Accelerated sudden rise in blood pressure in
patient with preexisting essential hypertension
2. Renovascular hypertension
3. Glomerulonephritis-acute
4. Eclampsia
5. Pheochromocytoma
6. Antihypertensive withdrawl syndromes
7. Head injuries
8. Renin secreting tumors
9. Ingestion of cathecolamine precursor in patients
taking MAO inhibitors

Evidence from a longitudinal study (Saguner AM et al, 2010):


Nonadherence was the most important factor
associated with hypertensive crises

• Saguner AM, Dur S, Perrig M, Schiemann, Stuck AE, Burgi U, et al. Risk Factors Promoting
Hypertensive Crises: Evidence From a Longitudinal Study. Am J Hypertens 2010; 23:775-780
Pathogenesis & Pathophysiogy
of HT Emergencies
Pathogenesis

MAP:70 MAP:150 MAP:180


(TD:90/60) (TD:180/120) (TD:220/160)

“Breakthrough Hyperperfusion”

Curves of CBF at varying levels of systemic BP


In normotensive and hypertensive subjects.
• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J, Tonelli M, Johnson RJ, editors.
Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
• Kaplan NM, Victor RG,Flynn JT. Hypertensive Emergencies. Kaplan’s Clinical Hypertension. 11 th edition. 2015.Wolters Kluwer.p.263-274
Pathogenesis
Sudden increase in Mechanical stress with endothelial injury:
Systemic Vascular Resistance • Increased permeability
• Coagulation/Platelet activation
• Fibrin deposition

“Breakthrough”
Hyperperfusin
1. Activation of RAS
2. Oxydative stress
3. Proinflammatory cytokines
4. Fibrinoid necrosis

A. Concentric subendothelial edematous


thickening (“onion-skin” appearance)
B. Collapsed glomerulus

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J, Tonelli M, Johnson RJ, editors.
Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
• Derhaschnig U, Testori C, Riedmueller, Aschauer S, Wolzt M, Jilma B. Hypertensive Emergencies are Associated with Elevated Markers of Inflammation,
Coagulation, Platelet Activation and Fibrinolysis.Journal of Human Hypertension (2013) 27, 368-373
Pathophysiology

Endothelium modulates Acute changes Endothelial control


vascular resistance vascular resistance overhelmed

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J, Tonelli M, Johnson RJ, editors.
Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
• Vaughan CJ, Delanty N. Hypertensive emergency. Lancet 2000; 356: 411-417
Elevated Biomarkers
of Inflammation, Coagulation, Platelet Activation and Fibrinolysis

Inflammatory Biomarkers Coagulation Biomarkers


and markers of fibrinolysis
• Derhaschnig U, Testori C, Riedmueller, Aschauer S, Wolzt M, Jilma B. Hypertensive Emergencies are Associated with Elevated Markers
of Inflammation, Coagulation, Platelet Activation and Fibrinolysis. Journal of Human Hypertension (2013) 27, 368-373
Diagnostic Work-up
for Patients with
Suspected HT Emergencies
Diagnostic Evaluation (1)
➢ The primary goal of diagnostic process is to differentiate a true
hypertensive emergency from a hypertensive urgency
➢ The second goal is rapid assessment of the type and severity
of ongoing target organ damage.
A. HISTORY:

HYPERTENSION HISTORY
SOCIAL HISTORY
• Last known BP (duration, severity)
• Smoking, alcohol
• Prior diagnosis and treatment
• Illicit drug (cocaine, stimulants)
• Dietary and social factors
• Possibility of pregnancy

MEDICATION HISTORY
FAMILY HISTORY
• Compliance to hypertensive tx/
• Early onset hypertension
• Steroid use
Cardiovascular and cerebrovascular
• Estrogens
Disease
• Sympathomimetics
• Diabetes
• MAO inhibitors
• Pheochromocytoma

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
Diagnostic Evaluation (2)

SYMPTOMS SPECIFIC HISTORY

• Cardiovascular:
- Previous MI/angina/arrhythmias
- Chest pain/SoB/flank or back pain
• Neurologic
- Prior stroke/neurodysfunction
- Visual changes, blurriness, loss of visual fields, severe
headache, nausea/vomiting, change of mental status
• Renal
- Underlying renal disease
- Anuria/oligouria
• Endocrine
- Diabetes, thyroid dysfunction, cushing’s syndrome

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
Diagnostic Evaluation (3)

B. PHYSICAL EXAMINATION

➢ Confirm elevated BP
• Proper positioning, appropriate cuff size
• Supine and standing and both arms

➢ Assess HMOD presence


• Funduscopy
• Neck: Thyroid, Carotid bruit, JVP
• CV: oxygen, saturation, enlarged heart, asymmetric pulse,
arrhythmias
• Pulmonary: crackers, ronchi
• Renal: bruit, abdominal masses
• Neurologic: concosiousness, evidence of stroke

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
Funduscoy
(Keith-Wagner-Barker Classification)

Normal Grade 1: Grade 2:


- Mild narrowing of the arterioles Moderate narrowing “Copper-Wire” and
- “Copper-Wire” AV nicking

Grade 3: Severe narrowing – Silver wire changes, Grade 4: Grade 3 + Papilledema


hemorrhage, cotton wool spots, hard exudates
General Principle
for managing HT Emergencies
HTN in Patient with Comorbidities (CV Disease)

MAP:150
(TD:180/120)

CBF (cerebral blood flow)


CPP (cerebral perfusion pressure)
CVR (cerebral venous resistance)
Under normal
condition, cerebral
MAP:180 MAP (mean arterial pressure)
ICP (intracranial pressure)
(TD:220/160)
blood flow (CBF): 50 JVP (jugular venous pressure)
ml/100 g/min

In the normal state, cerebral blood flow (CBF) is held constant across a wide range of
cerebral perfusion pressure (CPP: 70-150 mm Hg)
In chronic hypertension, the autoregulation curve shifts to the right
In the presence of acute cerebral ischemia, cerebral autoregulation may be impaired,
and CBF becomes dependent on CPP

• Aiyagari V, Osman M, Gorelick PB. Neurogenic Hypertension, Including Hypertension Associated With Stroke or Spinal Cord Injury. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology 2019. 6th edition. Elsevier.p. 473-481
Specific Aspect
of Anti-HTN Drug use for HTN Emergencies
Some Factors Involved in the
Regulation of Bood Pressure

• Elliott WJ, Lawton WJ. Normal Blood Pressure Control and the Evaluation of Hypertension. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology 2019. 6th edition. Elsevier.p. 444-452
Available Drug types in Indonesia
for treatment of Hypertension Emergencies
DRUG ONSET DURATION DOSE CONTRA ADVERSE
OF OF INDICATIONS EFFECTS
ACTION ACTION

1-5 min 3-5 min 5-200 μg/min i.v. infusion, Headache,


Nitroglycerine 5 μg/min increase every 5 min reflex
tachycardia

5-15 min 30-40 min 5-15 mg/h i.v. infusion, Liver failure Headache,
Nicardipine starting dose 5 mg/h, Reflex
Increase every 15-30 min with tachycardia
2.5 mg until goal BP,
thereafter decrease to 3 mg/h

1-2 min 5-8 h 2.5-5 mg i.v. bolus, 2nd or 3rd AV Bradycardia


Metoprolol maybe repeated every 5 min to block, systolic
a maximum of 15 mg heart failure,
asthma,
bradycardia

30 min 4-6 h 150-300 μg i.v. bolus over 5-10 Sedation,


Clonidine min rebound HT

• Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of
arterial hypertension. J Hypertens 2018; 36:1953-2041 and Eur Heart J 2018;39:3021-3104
Management of Specific Types
of Hypertensive Emergencies
1. Cardiac
TYPE OF EMERGENCY FIRST-CHOICE DRUG(S) SECOND-CHOICE OR DRUGS TO AVOID AIM OF BP
ADDITIONAL DRUG(S) REDUCTION

• Nitroglycerin, • Sodium • Diazoxide, • Improvement


• Coronary • Nicardipine nitropruside, • Hydralazine in cardiac
ischemia/ • Clevidipine • Esmolol (if heart perfusion
infarction • Labetalol failure absent)

• Nitroglycerin, • Sodium • Diazoxide, • Decrease in


• Heart failure, • Fenoldopam nitropruside • Hydralazine afterload
• Pulmonary • Clevidipine • Enalaprilat • β-blockers
edema • Loop diuretics

• Labetalol • Diazoxide, • Systolic BP


• Aortic dissection • Esmolol+Sodium • Hydralazine <100-120 mm
nitropruside Hg in 20 min
• Fenoldopam (if possible)
• Nicardipine

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
2. Renal
TYPE OF EMERGENCY FIRST-CHOICE SECOND-CHOICE DRUGS TO AVOID AIM OF BP REDUCTION
DRUG(S) OR ADDITIONAL
DRUG(S)

• Fenoldopam • Nicardipine • Sodium • Reduction in


• Acute • Labetalol nitroprusside vascular
glomerulonephritis • Clevedipine • ACE inhibitors resistance and
• Collagen vascular • Diuretics for • ARBs volume overload
renal disease volume
overload
• Renal artery
stenosis

• Enalaprilat • Angiotensin • Corticosteroids • Decrease in BP


• Scleroderma crisis • Other ACE receptor • diuretics <140/90 mm Hg
inhibitor blocker with long-term
• Fenoldopam goal of <130/85

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
3. Neurologic
TYPE OF EMERGENCY FIRST-CHOICE SECOND-CHOICE DRUGS AIM OF BP REDUCTION
DRUG(S) OR ADDITIONAL TO
DRUG(S) AVOID

• Nicardipine • Nitroprusside • 20%-25% reduction in mean


• Hypertensive • Fenoldopa • Esmolol BP over 1-2 hr
encephalopathy m • Urapidil
• Labetalol
• Clevidipine

• Nicardipine • Nitroprusside • Reduction of BP if above 220/120


• Ischemic stroke • Labetalol • Nimodipine mm Hg (mean BP >130) by no
more than 10%-15% within first 24
• Clevidipine • Esmolol
hr to avoid impairing cerebral
• Urapidil blood flow in penumbra
• SBP 150-220 mm Hg and without
• Nicardipine • Fenoldopam contraindication to acute BP
• Intracerebral • Labetalol • Nitroprusside treatment: decrease SBP to 140
hemorrhage • Clevidipine • Esmolol
mm Hg, as it is safe and can
improve functional outcome.
• Urapidil • SBP >220 mm Hg: aggressive
• Nimodipine reduction of BP with continuous
for intravenous infusion and frequent
subarachnoid BP monitoring.
• Subarachnoid hemorrhage in
hemorrhage
normotensive patients: reduction
to systolic BP of 130-160 mm Hg

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
4. Cathecolamine Excess States
TYPE OF EMERGENCY FIRST-CHOICE SECOND-CHOICE OR DRUGS TO AIM OF BP
DRUG(S) ADDITIONAL DRUG(S) AVOID REDUCTION

• Phentolamine • β-blockers in the • Diuretics, • Control of BP


• Pheochromocytoma • Labetalol presence of • β-blockers paroxysms from
phentolamine alone sympathetic
• Sodium stimulation
nitropruside

• Phentolamine • β-blockers in the • Diuretics, • Control of BP


• Ingestion of cocaine • Labetalol presence of paroxysms from
or other phentolamine sympathetic
sympatomimetic • Sodium stimulation
nitropruside

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
5. Perioperative/Postoperative HT
TYPE OF EMERGENCY FIRST-CHOICE SECOND-CHOICE OR DRUGS TO AIM OF BP REDUCTION
DRUG(S) ADDITIONAL DRUG(S) AVOID

• Nitroglycerin • Esmolol, • Protection againt


• Coronary artery • Nicardipine • Labetalol target organ
surgery • Clevidipine • Fenoldopam damage and
• Isradipine surgical
• Urapidil complications
(keep BP <140/90
or mean BP <105
mm Hg)

• Esmolol, • Protection againt


• Non-cardiac • Labetalol target organ
surgery • Fenoldopam damage and
• Nicardipine surgical
• Clevidipine complications
• Urapidil
• Nitroglycerin

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
6. Pregnancy related
TYPE OF EMERGENCY FIRST-CHOICE SECOND-CHOICE OR DRUGS TO AVOID AIM OF BP REDUCTION
DRUG(S) ADDITIONAL DRUG(S)

• Eclampsia • Labetalol • Nifedipine • Nitroprusside • Control BP


• Urapidil • Isradipine • ACE inhibitors (typically <90 mm
• Nicardipine • ARB Hg diastolic but
• MgSO4 often lower) and
• Methyldopa protect placental
• Hydralazine blood flow

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
Hypertensive Urgencies
DRUG MECHANISM OF DOSE ONSET DURATION OF ADVERSE EFFECTS
ACTION OF ACTION ACTION

Captopril ACE inhibitor 12.5-25 mg PO 15-30 min 4-6 hr Angioedema,


every 1-2 hr cough, acute renal
failure
Clonidine Central α2- 0.1-0.2 mg PO 30-60 min 6-8 hr Sedation, dry mouth,
agonist every 1-2 hr bradycardia,
rebound
hypertension after
withdrawal
Labetalol α1-, β-Blocker 200-400 mg PO 30-120 min 6-8 hr Bronchoconstriction,
every 2-3 hr heart block,
congestive heart
failure
Furosemide Loop diuretik 20-40 mg PO 30-60 min 8-12 hr Volume depletion,
every 2-3 hr hyponatremia,
hypokalemia
Isradipine Calcium channel 5-10 mg PO 30-90 min 8-16 hr Headache,
blocker every 4-6 hr tachycardia,
flushing, peripheral
edema

• Sarafidis PA, Bakris GL. Evaluation and Treatment of Hypertensive Emergencies and Urgencies. In: Feehally J, Floege J,
Tonelli M, Johnson RJ, editors. Comprehensive Clinical Nephrology. 6th edition. 2019. Elsevier.p. 444-452
TAKE HOME MESSAGE
• In assessing HTN crises, emphasis should be made on
the rate of rise of BP rather than the absolute level of BP
itself

• When end-organ dysfunction is present in HTN


emergencies, patients need prompt control of BP
preferably using intravenous agents

• Type of HMOD dictates the target BP and drug choices

• Among the limited numbers of intravenous drug to


treat HTN emergencies, nicardipine as either first
choice or alternative in most of the various forms of
HTN emergencies.
Thank You
❑ Class of Recommendation (COR)
❑ Level of Evidence (LOE)