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erin or an intravenous -blocker, such as labetalol or esmolol, is preferable 1 Nitroprusside sodium This agent is given by controlled intravenous infusion gradually titrated to the desired effect It lowers the blood pressure within seconds by direct arteriolar and venous dilation Monitoring with an intra-arterial line avoids hypotension Nitroprusside in combination with a -blocker is especially useful in patients with aortic dissection 2 Nitroglycerin, intravenous This agent is a less potent antihypertensive than nitroprusside and should be reserved for patients with accompanying acute ischemic syndromes 3 Labetalol This combined - and -blocking agent is the most potent adrenergic blocker for rapid blood pressure reduction Other -blockers are far less potent Excessive blood pressure drops are unusual Experience with this agent in hypertensive syndromes associated with pregnancy has been favorable 4 Esmolol This rapidly acting -blocker is approved only for treatment of supraventricular tachycardia but is often used for lowering blood pressure It is less potent than labetalol and should be reserved for patients in whom there is particular concern about serious adverse events related to -blockers 5 Nicardipine Intravenous nicardipine is the most potent and the longest acting of the parenteral calcium channel blockers As a primarily arterial vasodilator, it has the potential to precipitate reflex tachycardia, and for that reason it should not be used without a -blocker in patients with coronary artery disease 6 Fenoldopam Fenoldopam is a peripheral dopamine1 (DA1) receptor agonist that causes a dose-dependent reduction in arterial pressure without evidence of tolerance, rebound, or withdrawal or deterioration of renal function In higher dosage ranges, tachycardia may occur 7 Enalaprilat This is the active form of the oral ACE inhibitor enalapril The onset of action is usually within 15 minutes, but the peak effect may be delayed for up to 6 hours Thus, enalaprilat is used primarily as an adjunctive agent 8 Diazoxide Diazoxide acts promptly as a vasodilator without decreasing renal blood flow To avoid hypotension, it should be given in small boluses or as an infusion rather than as the previously recommended large bolus One use of diazoxide has been in preeclampsia-eclampsia Hyperglycemia and sodium and water retention may occur The drug should be used only for short periods and is best combined with a loop diuretic 9 Hydralazine Hydralazine can be given intravenously or intramuscularly, but its effect is less predictable than that of other drugs in this group It produces reflex tachycardia and should not be given without -blockers in patients with possible coronary disease or aortic dissection Hydralazine is now used primarily in pregnancy and in
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A growing number of agents are available for management of acute hypertensive problems (Table 11 12 lists drugs, dosages, and adverse effects) Sodium nitroprusside is the agent of choice for the most serious emergencies because of its rapid and easily controllable action, but continuous monitoring is essential when this agent is used In the presence of myocardial ischemia, intravenous nitroglyc-
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Table 11 12 Drugs for hypertensive emergencies and urgencies
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Agent Nitroprusside (Nipride) Action Vasodilator Dosage 025 10 mcg/kg/min Onset Seconds Duration 3 5 minutes Adverse Effects GI, CNS; thiocyanate and cyanide toxicity, especially with renal and hepatic insufficiency; hypotension Headache, nausea, hypotension, bradycardia GI, hypotension, bronchospasm, bradycardia, heart block Bradycardia, nausea Comments Most effective and easily titratable treatment Use with -blocker in aortic dissection Tolerance may develop Useful primarily with myocardial ischemia Avoid in congestive heart failure, asthma May be continued orally Avoid in congestive heart failure, asthma Weak antihypertensive May protect renal function
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Vasodilator
025 5 mcg/kg/min
2 5 minutes 5 10 minutes
3 5 minutes 3 6 hours
Labetalol (Normodyne, Trandate) Esmolol (Brevibloc)
- and Blocker
20 40 mg every 10 minutes to 300 mg; 2 mg/ min infusion Loading dose 500 mcg/ kg over 1 minute; maintenance, 25 200 mcg/kg/min 01 16 mcg/kg/min
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