. 2022 Nov 22;37(10):863–879. doi: 10.1038/s41371-022-00776-9

Table 2.

Pharmacotherapy considerations and choices for hypertensive crises states.

Hypertensive states and suggested plan of action	Pharmacotherapy choices
Acute severe hypertension Confirm hypertension, re-assess in 7 days, undertake secondary screen if applicable. Confirm adherence in known hypertension. Aim to achieve target BP in 6–12 weeks	Confirmed new hypertension: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or calcium channel blocker as per NG 136 Pre-existing hypertension: increase doses of current medications, consider adding medications as per NG 136
Malignant hypertension/accelerated hypertension (eye changes only) Start oral therapy, monitor response, arrange frequent follow up Aim to achieve target BP in days to weeks (preferably by 6 weeks, at the least by 12 weeks)	Oral atenolol 25 mg OR Oral amlodipine 5 mg/Or oral long acting nifedipine 30 mg^a
Hypertensive encephalopathy Invasive BP monitoring Reduce mean arterial pressure (MAP) by no more than 20–25% over few hours and/or Reduce diastolic BP (DBP) to 100–110 mmHg	IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/h continuous infusion, adjusting every 15 mins OR IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 min, not exceeding 15 mg/h overall
Intracerebral haemorrhage Invasive BP monitoring Reduce systolic BP (SBP) by 20–25% BP targets in the range of 140–180 mmHg SBP and 90–110 mmHg DBP	IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/hr continuous infusion, adjusting every 15 min OR IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall
Ischaemic stroke Reduce BP only if specific criteria met δ. Reduce MAP by no more than 15% in patients with BP ≥ 220/120 mmHg	IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over a minute, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/hr continuous infusion, adjusting every 15 min OR IV nicardipine 3-5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall
Subarachnoid haemorrhage Pain control is essential Weigh benefits and risks of reduction in BP considering cerebral vasospasm and hypoperfusion Target SBP range 140–180 mmHg	Nimodipine 60 mg orally, nasogastric, or gastric tube every 4 h, usually started within 96 h of onset of subarachnoid haemorrhage and continued for 21 days. Oral therapy preferred over other routes.
Acute aortic syndromes Pain, and anxiety control is crucial Invasive BP monitoring Reduce HR to <60 bpm, and Reduce SBP to 120 mmHg while monitoring for adequate perfusion through the false lumen	IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/h continuous infusion, adjusting every 15 min OR IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall OR IV nitroprusside initially started at 0.5–1.5 mcg/kg/min increased every 5 min by 0.5 mcg/kg/min if necessary, usual maintenance dose 10–200 mcg/min.
Acute coronary syndrome Prioritise revascularisation treatment strategy, pain and anxiety management Reduce SBP/ MAP by no more than 20–25% and avoid DBP < 70 mmHg	IV Glyceryl Trinitrate (GTN) started at 15–20 mcg/min, can increase/decrease by 5–10 mcg/min every 15–30 min, overall dose adjustment as per individual needs are met. OR IV labetalol 20 mg/h infusion, adjust every 15 min, can be administered in intermittent boluses
Left ventricular failure/Pulmonary oedema Reduce SBP/ MAP by not more than 20–25%	IV GTN 5-200 mcg/min (starting doses can start from 20–25 mcg/min), can increase/decrease by 10–15 mcg/min subsequently until required effect achieved. IV furosemide 40–80 mg (0.5–2 mg/kg) for relief of congestive symptoms (can be administered as infusion or IV boluses, subsequently oral)
Severe pre-eclampsia/eclampsia Reduce to target BP of pre-pregnancy level or ≤140/90 mm Hg in hypertension-naïve patients, reduce SBP by not more than 20% MAP in patients with very high BP values (>200/120 mmHg). Consider benefits and risks of delivery versus expectant management (NG133) Monitor maternal and foetal parameters closely.	IV magnesium, loading dose 4 g over 5–15 min followed by infusion of 1 g/h for 24 h, further dose of 2–4 g given over 5–15 min if recurrent seizures. Labetalol 200 mg oral stat or slow IV bolus injection 50 mg (over 1–2 min) which can be repeated. If IV infusion is required, at ~20–40 mg/h, up titrate as necessary. Consider addition of oral long acting nifedipine. Consider IV hydralazine slow IV injection 5–10 mg which maybe repeated or IV infusion 200–300 mcg/min: usual maintenance 50–150 mcg/min. monitor for fluid and volume status.
Phaeochromocytoma/ adrenergic crisis Maintain adequate hydration	Alpha blockade with phenoxybenzamine starting at 10 mg/day, with volume expansion using fluid and salt. Phentolamine may be used where available. Doxazosin 1–2 mg starting doses may be a suitable alternative. Beta-blockers are employed only if tachycardia ensues

Hypertensive states and suggested plan of action

Pharmacotherapy choices

Acute severe hypertension

Confirm hypertension, re-assess in 7 days, undertake secondary screen if applicable.

Confirm adherence in known hypertension.

Aim to achieve target BP in 6–12 weeks

Confirmed new hypertension: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or calcium channel blocker as per NG 136

Pre-existing hypertension: increase doses of current medications, consider adding medications as per NG 136

Malignant hypertension/accelerated hypertension (eye changes only)

Start oral therapy, monitor response, arrange frequent follow up

Aim to achieve target BP in days to weeks (preferably by 6 weeks, at the least by 12 weeks)

Oral atenolol 25 mg

Oral amlodipine 5 mg/Or oral long acting nifedipine 30 mg^a

Hypertensive encephalopathy

Invasive BP monitoring

Reduce mean arterial pressure (MAP) by no more than 20–25% over few hours and/or

Reduce diastolic BP (DBP) to 100–110 mmHg

IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/h continuous infusion, adjusting every 15 mins

IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 min, not exceeding 15 mg/h overall

Intracerebral haemorrhage

Invasive BP monitoring

Reduce systolic BP (SBP) by 20–25%

BP targets in the range of 140–180 mmHg SBP and 90–110 mmHg DBP

IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/hr continuous infusion, adjusting every 15 min

IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall

Ischaemic stroke

Reduce BP only if specific criteria met δ. Reduce MAP by no more than 15% in patients with BP ≥ 220/120 mmHg

IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over a minute, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/hr continuous infusion, adjusting every 15 min

IV nicardipine 3-5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall

Subarachnoid haemorrhage

Pain control is essential

Weigh benefits and risks of reduction in BP considering cerebral vasospasm and hypoperfusion

Target SBP range 140–180 mmHg

Nimodipine 60 mg orally, nasogastric, or gastric tube every 4 h, usually started within 96 h of onset of subarachnoid haemorrhage and continued for 21 days. Oral therapy preferred over other routes.

Acute aortic syndromes

Pain, and anxiety control is crucial

Invasive BP monitoring

Reduce HR to <60 bpm, and

Reduce SBP to 120 mmHg while monitoring for adequate perfusion through the false lumen

IV labetalol bolus 0.25–0.5 mg/kg (usually 50 mg bolus given over 1–2 min, repeated within 5 min if necessary, not exceeding 200 mg), or can be administered as 15–20 mg/h continuous infusion, adjusting every 15 min

IV nicardipine 3–5 mg/h for 15 min, adjust with increments of 0.5 or 1 mg every 15 mins, not exceeding 15 mg/h overall

IV nitroprusside initially started at 0.5–1.5 mcg/kg/min increased every 5 min by 0.5 mcg/kg/min if necessary, usual maintenance dose 10–200 mcg/min.

Acute coronary syndrome

Prioritise revascularisation treatment strategy, pain and anxiety management

Reduce SBP/ MAP by no more than 20–25% and avoid DBP < 70 mmHg

IV Glyceryl Trinitrate (GTN) started at 15–20 mcg/min, can increase/decrease by 5–10 mcg/min every 15–30 min, overall dose adjustment as per individual needs are met.

IV labetalol 20 mg/h infusion, adjust every 15 min, can be administered in intermittent boluses

Left ventricular failure/Pulmonary oedema

Reduce SBP/ MAP by not more than 20–25%

IV GTN 5-200 mcg/min (starting doses can start from 20–25 mcg/min), can increase/decrease by 10–15 mcg/min subsequently until required effect achieved.

IV furosemide 40–80 mg (0.5–2 mg/kg) for relief of congestive symptoms (can be administered as infusion or IV boluses, subsequently oral)

Severe pre-eclampsia/eclampsia

Reduce to target BP of pre-pregnancy level or ≤140/90 mm Hg in hypertension-naïve patients, reduce SBP by not more than 20% MAP in patients with very high BP values (>200/120 mmHg).

Consider benefits and risks of delivery versus expectant management (NG133)

Monitor maternal and foetal parameters closely.

IV magnesium, loading dose 4 g over 5–15 min followed by infusion of 1 g/h for 24 h, further dose of 2–4 g given over 5–15 min if recurrent seizures.

Labetalol 200 mg oral stat or slow IV bolus injection 50 mg (over 1–2 min) which can be repeated. If IV infusion is required, at ~20–40 mg/h, up titrate as necessary. Consider addition of oral long acting nifedipine.

Consider IV hydralazine slow IV injection 5–10 mg which maybe repeated or IV infusion 200–300 mcg/min: usual maintenance 50–150 mcg/min. monitor for fluid and volume status.

Phaeochromocytoma/ adrenergic crisis

Maintain adequate hydration

Alpha blockade with phenoxybenzamine starting at 10 mg/day, with volume expansion using fluid and salt. Phentolamine may be used where available. Doxazosin 1–2 mg starting doses may be a suitable alternative. Beta-blockers are employed only if tachycardia ensues

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

^aLong-acting calcium channel blocker such as Adalat La 30 mg may be considered when available. Do not use short-acting nifedipine. δ1. If BP is greater than >220/120 mmHg in the acute phase. Lower MAP by no more than 15% over 24 h. 2. Reduce BP to 185/110 mmHg if patient is a candidate for thrombolysis 3. Reduce BP according to the concomitant emergency state as indicated. Please consult local guidelines, when available. Specialist advise should be sought for each hypertensive state, such as in the presence of renal dysfunction seek renal specialist/team advice.