Table 14.
Comparison of international guidelines of American Heart Association (AHA)/American College of Cardiology (ACC) and European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines and hypertensive emergencies position paper and National Institute for Health and Care Excellence (NICE) guidelines for management of hypertensive emergency states and current British and Irish Hypertension Society (BIHS) position.
| Hypertensive crisis state | ESC/ESH European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines/position | American Heart Association (AHA)/American College of Cardiology (ACC) guidelines | National Institute for Health and Care Excellence (NICE) guidelines | BIHS position |
|---|---|---|---|---|
| Terms used | Urgencies and emergencies | Urgencies and emergencies included as crisis | Severe hypertension, accelerated hypertension also known as malignant hypertension | Acute severe hypertension, accelerated/ malignant hypertension, hypertensive emergency |
| Blood pressure (BP) values for diagnosis | >180/120 mmHg | ≥180/120 mmHg (and often >220/120 mmHg) (NG136) | ≥180/120 mmHg for acute severe hypertension, no specific cut off BP value for hypertensive emergencies | |
| BP targets and recommendations on therapy in various hypertensive emergencies and acute severe hypertension | ||||
| Condition | ESC/ESH guidelines | AHA guidelines | NICE guidelines | BIHS position |
| Malignant hypertension (MHT)/ accelerated hypertension without hypertensive encephalopathy |
Reduce mean arterial pressure (MAP) 20–25% over several hours. Drug of choice: labetalol or nicardipine. |
Not explicitly defined | For uncomplicated MHT (eye changes only), oral medications amlodipine/ atenolol with monitoring and frequent follow up. Reach target BP (<135/85 mmHg at home) within days to weeks (6–12 weeks) | |
| Hypertensive encephalopathy | Reduce MAP 20-25% at once with labetalol or nicardipine | Not explicitly defined however overall, for all hypertensive emergencies with a few exceptions, -reduce BP by max 25% over first hour, then to 160/100–110 mmHg over next 2–6 h then to normal over 24–48 h | Reduce MAP by no more than 20–25% over several hours and/or reduce DBP to 110 and 100 mmHg within 24 h | |
| Ischaemic stroke | If BP > 220/120 mmHg or if considered for thrombolytic therapy and BP > 185/110 mmHg reduce MAP 15% in 1 h. |
Lower SBP to <185 mmHg and DBP < 110 mmHg before initiation of IV thrombolysis. Maintain BP < 180/105 mmHg for first 24 h after IV thrombosis. If BP > 220/120 mmHg reduce MAP 15% in 24 h. |
BP reduction to 185/110 mmHg considered in people who are candidates for IV thrombolysis. Anti-hypertensive treatment only if overlap with another hypertensive emergency |
If BP is greater than >220/120 mmHg, reduce by 10–15% MAP within 24 h. If BP ≤ 220/120 consider reducing to 185/110 mmHg if thrombolysis/thrombectomy indicated. Aim for BP < 140/90 mmHg prior to discharge. |
| Intracerebral haemorrhage | If SBP > 180 mmHg, immediate reduction to 130–180 mmHg range (especially if initial BP ≥ 220 mmHg) with labetalol or nicardipine | Reducing BP to <140 mmHg can be potentially harmful | If presented within 6 h of ICH and SBP 150–220 mmHg, reduce BP rapidly. If presented beyond 6 h after stroke, consider same targets if SBP > 220 mm Hg. To consider risk of harm case by case. List of exclusions for rapid BP lowering explicitly mentioned (NG 128). |
Appropriate targets are generally in the range of SBP 140–180 or DBP 90–110 mmHg. Reduction based on presenting BP values. If BP > 220/120 mmHg, consider a smooth reduction in MAP no more than 20–25% over several hours (SBP should be kept ≥140 mmHg, preferably around 140–160 mmHg). |
| Acute coronary syndrome (ACS), acute pulmonary oedema/hypertensive heart failure | Reduce SBP to <140 mmHg immediately on both conditions. ACS treated with GTN, labetalol. Pulmonary oedema treated with GTN or nitroprusside (with loop diuretic) | ACS treated with esmolol or labetalol, GTN, nicardipine. Pulmonary oedema treated with clevidipine, GTN or nitroprusside |
For acute coronary syndrome: Routine immediate reduction in BP is not recommended. Adequate analgesia and maintenance of oxygenation are first steps. Prioritise revascularisation therapy over BP therapy. Do not reduce DBP below 70 mmHg. Aim for BP < 140/90 mmHg at the time of discharge Hypertensive heart failure: reduce MAP by not more than 25% reduction. |
|
| Acute aortic disease | Reduce SBP to <120 mmHg AND heart rate to <60 bpm with esmolol and nitroprusside or GTN or nicardipine | Reduce SBP to <120 mmHg within 20 min with esmolol or labetalol | Aim SBP reduction to 120 mmHg and heart rate reduction to ≤60 bpm. The target BP should allow adequate maintenance of vital organ perfusion and consider co-existing co-morbidities. Ensure adequate analgesia and agitation control | |
| Severe pre-eclampsia | Reduce SBP to <160/105 mmHg in the first hour (immediate) with labetalol or nicardipine and magnesium sulphate | Rapid lowering. Reduce SBP to <140 mmHg in the first hour | Severe hypertension in pregnancy is >160/110 mmHg. Aim for BP < 135/85 mmHg |
Consider BP target ≤140/90 mmHg. As a first step, reduce BP to <160/100 mmHg. If known chronic hypertension a target related to pre-pregnancy or booking BP may be more appropriate. If >200/120 mmHg a target of 160/100 mmHg may be more appropriate. Avoid rapid drops in BP and adequate maternal and foetal monitoring |
| Pheochromocytoma crisis/ Adrenergic crisis | Treat with phentolamine, nitroprusside, and urapidil or nicardipine used in per-operative period | Reduce SBP to <140 mmHg during the first hour. Phentolamine and labetalol are useful. |
α blockade with oral phenoxybenzamine (if unavailable doxazosin can be used). IV Phentolamine if available in a crisis. Benzodiazepines for illicit drug-induced hypertension such as cocaine-induced, and amphetamine induced |
|
ACS acute coronary syndrome, BP blood pressure, MAP mean arterial pressure, SBP systolic blood pressure, DBP diastolic blood pressure, NG- NICE guidelines, EOD end organ damage, GTN glyceryl trinitrate, MHT malignant hypertension, ICH intracerebral haemorrhage, AIS acute ischaemic stroke.