Management – Overview

The goal of treatment is to safely lower blood pressure to halt progressive end-organ damage. However, overly rapid reduction may further impair perfusion to vulnerable tissues. General management principles include:

• Parenteral antihypertensive therapy to provide predictable effects and easy titration
• Continuous infusions preferred over intermittent IV boluses
• BP lowering not more than 25% in the first hour, then to 160/100-110 mm Hg over 2-6 hours, then to normal over 24-48 hours
• More rapid reduction needed for aortic dissection, severe preeclampsia/eclampsia
• Choice of agent depends on type of end-organ damage and patient factors
• Transition to oral antihypertensives when target organ damage is controlled

First-line parenteral options include nicardipine, clevidipine, nitroprusside, and nitroglycerin. Alternative agents like labetalol, hydralazine, and fenoldopam may have a role in certain clinical scenarios. Non-pharmacological interventions include close monitoring, ICU care, procedures to treat organ damage (e.g. revascularization for MI), and addressing secondary causes. In summary, treatment focuses on careful titration of parenteral agents to avoid extremes of either uncontrolled hypertension or overly rapid reduction.