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Pathophysiology and Pharmacotherapy of Cardiovascular Disease pp 869–886Cite as

Vasodilators and Management of Hypertensive Emergencies

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Abstract

Hypertensive emergency is an important clinical entity, which may result in end-organ damage involving neurological, cardiovascular, and renal systems. If not recognized and acted upon promptly, it can result in life-threatening adverse outcomes. Vasodilators form the mainstay of treatment in hypertensive emergencies. There are different classes of vasodilators based on the site and mechanism of action. The most commonly used vasodilators include directly acting drugs that act via the vascular nitric oxide pathway, calcium channel blockers, beta blockers, alpha blockers, and peripheral dopamine agonists. The various classes of vasodilators act via different neurohormonal signaling pathways and reduce the blood pressure by decreasing the peripheral resistance. Despite the availability of several medications, there is still paucity of literature regarding the best antihypertensive medication to be employed as well as the ideal rate of decreasing the elevated blood pressure in a given clinical scenario. This chapter reviews the basic pharmacology and the mechanism of action of commonly used vasodilators. It also reviews the approach to choosing the most appropriate drug based on the target organ involvement in diverse clinical scenarios of hypertensive emergency.

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References

  1. World Health Organization. A global brief on hypertension: silent killer, global public health crisis. World Health Day 2013. Report, 1–39. Geneva: World Health Organization; 2013.

    Google Scholar 

  2. Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006;24:135–46.

    Article  PubMed  Google Scholar 

  3. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Hypertension. 2003;42:1206–52.

    Article  CAS  PubMed  Google Scholar 

  4. Kaplan NM. Management of hypertensive emergencies. Lancet. 1994;344(8933):1335.

    Article  CAS  PubMed  Google Scholar 

  5. Cherney D, et al. Management of patients with hypertensive urgencies and emergencies. J Gen Intern Med. 2002;17(12):937.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Gordon AC, Myburgh JA. Vasodilators and antihypertensives. In: Berstein AD, Soni N, editors. Oh’s intensive care manual. 7th ed. Butterworth Heinemann, Elsevier Ltd, Oxford; 2014; Chapter 91; p. 923–34.

    Google Scholar 

  7. Harrison DG, Luther JM. Vascular Pharmacology. In: Creager MA, Beckman JA, Loscalzo, editors. Vascular medicine: a companion to Braunwald’s heart disease. 2nd ed. Saunders Elsevier, Philadelphia; 2006; Chapter 6; p. 75–93.

    Google Scholar 

  8. Friederich JA, Butterworth JF. Sodium nitroprusside: twenty years and counting. Anesth Analg. 1995;81:152–62.

    CAS  PubMed  Google Scholar 

  9. Cherney D, Straus S. Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. J Gen Intern Med. 2002;17:937–45.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Tighe DA, Tran MT, Donovan LJ, Cook JR. Cardiology drug guide 2010. Sudbury: Jones and Bartlett Publishers; 2010.

    Google Scholar 

  11. Alldredge BK, Corelli RL, Ernst ME, Guglielmo BJ, Jacobson PA, Kradjan WA, et al. Koda-Kimble & Young’s applied therapeutics: the clinical use of drugs. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.

    Google Scholar 

  12. Griswold WR, Reznik V, Mendoza SA. Nitroprusside-induced intracranial hypertension. JAMA. 1981;246:2679–80.

    Article  CAS  PubMed  Google Scholar 

  13. Anile C, Zanghi F, Bracali A, Maira G, Rossi GF. Sodium nitroprusside and intracranial pressure. Acta Neurochir (Wien). 1981;58:203–11.

    Article  CAS  Google Scholar 

  14. Mann T, Cohn PF, Holman LB, et al. Effect of nitroprusside on regional myocardial blood flow in coronary artery disease. Results in 25 patients and comparison with nitroglycerin. Circulation. 1978;57:732–8.

    Article  CAS  PubMed  Google Scholar 

  15. Cohn JN, Franciosa JA, Francis GS, et al. Effect of short-term infusion of sodium nitroprusside on mortality rate in acute myocardial infarction complicated by left ventricular failure: results of a Veterans Administration cooperative study. N Engl J Med. 1982;306:1129–35.

    Article  CAS  PubMed  Google Scholar 

  16. Chen Z, Foster MW, Zhang J, et al. An essential role for mitochondrial aldehyde dehydrogenase in nitroglycerine bio activation. Proc Natl Acad Sci U S A. 2005;102(34):12159–64.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  17. Munzel T, Daiber A, Mulsch A. Explaining the phenomenon of nitrate tolerance. Circ Res. 2005;97:618–28.

    Article  PubMed  Google Scholar 

  18. Pollack CV, Rees CJ. Hypertensive emergencies: acute care evaluation and management. Emergency Medicine Cardiac Research and Education Group. Dec 2008; Vol 3.

    Google Scholar 

  19. Reece PA, Cozamanis I, Zacest R. Kinetics of hydralazine and its main metabolites in slow and fast acetylators. Clin Pharmacol Ther. 1980;28:769–78.

    Article  CAS  PubMed  Google Scholar 

  20. Sear JW. Antihypertensive drugs and vasodilators. In: Hemmings HC, Egan TD, editors. Pharmacology and physiology for anesthesia: foundations and clinical applications. Saunders Elsevier, Philadelphia; 2013, Chapter 6; p. 405–25.

    Google Scholar 

  21. Shepherd AM, Ludden TM, McNay JL, Lin MS. Hydralazine kinetics after single and repeated oral doses. Clin Pharmacol Ther. 1980;28:804–11.

    Article  CAS  PubMed  Google Scholar 

  22. Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007;131:1949–62.

    Article  CAS  PubMed  Google Scholar 

  23. Graham DJM, Dow RJ, Hall DJ, et al. The metabolism and pharmacokinetics of nicardipine hydrochloride in man. Br J Clin Pharmacol. 1985;20:23S–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  24. Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part1. Am J Health Syst Pharm. 2009;66(15):1343–52. doi:10.2146/ajhp080348.p1.

    Article  CAS  PubMed  Google Scholar 

  25. Rosenbaum D, Zabramski J, Frey J, et al. Early treatment of ischemic stroke with a calcium antagonist. Stroke. 1991;22:437–41.

    Article  CAS  PubMed  Google Scholar 

  26. Psaty BM, Heckbert SR, Koepsell TD, et al. The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA. 1995;274(8):620.

    Article  CAS  PubMed  Google Scholar 

  27. Deeks ED, Keating GM, Keam SJ. Clevidipine: a review of its use in the management of acuter hypertension. Am J Cardiovasc Drugs. 2009;9(2):117–34.

    Article  CAS  PubMed  Google Scholar 

  28. Cleviprex™ [package insert] Graz, Austria: Fresenius Kabi Austria GmbH; 2011.

    Google Scholar 

  29. Pollack CV, Varon J, Garrison NA, et al. Clevidipine, an intravenous dihydropyridine calcium channel blocker, is safe and effective for the treatment of patients with acute severe hypertension. Ann Emerg Med. 2009;53:329–38.

    Article  PubMed  Google Scholar 

  30. Levy JH, Mancao MY, Gitter R, et al. Clevidipine effectively and rapidly controls elevated blood pressure preoperatively in cardiac surgery patients: the results of the randomized, placebo-controlled efficacy study of clevidipine assessing its preoperative hypertensive effect in cardiac surgery-1. Anesth Analg. 2007;105:918–25.

    Article  CAS  PubMed  Google Scholar 

  31. Singla N, Warltier DC, Gandhi SD, et al. Treatment of acute postoperative hypertension in cardiac surgery patients: an efficacy study of clevidipine assessing its postoperative antihypertensive effect in the cardiac surgery-2 (ESCAPE-2), a randomized, double-blind, placebo controlled trial. Anesth Analg. 2008;107:59–67.

    Article  CAS  PubMed  Google Scholar 

  32. Richards DA, Tuckman J, Prichard BN. Assessment of alpha and beta adrenoreceptor blocking actions of labetalol. Br J Clin Pharmacol. 1976;3(5):849–55.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Kanto J, Allonen H, Kleimola T, Mäntylä R. Pharmacokinetics of labetalol in healthy volunteers. Int J Clin Pharmacol Ther Toxicol. 1981;19:41–4.

    CAS  PubMed  Google Scholar 

  34. Marx PG, Reid DS. Labetalol infusion in acute myocardial infarction with systemic hypertension. Br J Clin Pharmacol. 1979;8:233S–8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  35. Olsen KS, Svendsen LB, Larsen FS, Paulson OB. Effect of labetalol on cerebral blood flow, oxygen metabolism and autoregulation in healthy humans. Br J Anaesth. 1995;75:51–4.

    Article  CAS  PubMed  Google Scholar 

  36. Adams Jr HP, del Zoppo G, Alberts MJ, et al. Guidelines of the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association, Clinical Cardiology Council, Cerebrovascular Radiology and Interventional Council and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research and Interdisciplinary Working groups. Stroke. 2007;38:1655–722.

    Article  PubMed  Google Scholar 

  37. Pickles CJ, Broughton Pipkin F, Symonds EM. A randomised placebo controlled trial of labetalol in the treatment of mild to moderate pregnancy induced hypertension. Br J Obstet Gynaecol. 1992;99:964–8.

    Article  CAS  PubMed  Google Scholar 

  38. Bodmann KF, Tröster S, Clemens R, Schuster HP. Hemodynamic profile of intravenous fenoldopam in patients with hypertensive crisis. Clin Investig. 1993;72:60–4.

    Article  CAS  PubMed  Google Scholar 

  39. Munger MA, Rutherford WF, Anderson L, et al. Assessment of intravenous fenoldopam mesylate in the management of severe systemic hypertension. Crit Care Med. 1990;18:502–4.

    Article  CAS  PubMed  Google Scholar 

  40. White WB, Radford MJ, Gonzalez FM, et al. Selective dopamine-1 agonist therapy in severe hypertension: effects of intravenous fenoldopam. J Am Coll Cardiol. 1988;11:1118–23.

    Article  CAS  PubMed  Google Scholar 

  41. Shusterman NH, Elliott WJ, White WB. Fenoldopam, but not nitroprusside, improves renal function in severely hypertensive patients with impaired renal function. Am J Med. 1993;95:161–8.

    Article  CAS  PubMed  Google Scholar 

  42. Elliott WJ, Weber RR, Nelson KS, et al. Renal and hemodynamic effects of intravenous fenoldopam versus nitroprusside in severe hypertension. Circulation. 1990;81:970–7.

    Article  CAS  PubMed  Google Scholar 

  43. Tumlin JA, Dunbar LM, Oparil S, et al. Fenoldopam, a dopamine agonist, for hypertensive emergency: a multicenter randomized trial. Fenoldopam Study Group. Acad Emerg Med. 2000;7:653–62.

    Article  CAS  PubMed  Google Scholar 

  44. Corlapam® [package insert] Lake Forest, IL: Hospira Inc 2006

    Google Scholar 

  45. Miescher K, Marxer A, Urech E. U.S. Patent 2,503,059. 1950. http://www.google.com/patents/US2503059. Accessed on 2 Aug 2014.

  46. Dart RC. Medical toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 719.

    Google Scholar 

  47. Monthly index of Medical Specialities (MIMS). Phentolamine. http://www.mims.com/USA/drug/info/phentolamine/?q=Phentolamine&mtype=generic. Accessed on 1 Sept 2014.

  48. Anderson CS, Heeley E, Huang Y, et al. INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355–65.

    Google Scholar 

  49. Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. American Heart Association Stroke Council and Council on Cardiovascular Nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108.

    Google Scholar 

  50. Sen J, Belli A, Albon H, et al. Triple-H therapy in the management of aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2003;2:614–21.

    Article  PubMed  Google Scholar 

  51. He J, Zhang Y, Xu T, et al. The CATIS Investigators. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA. 2014;311(5):479–89.

    Google Scholar 

  52. Sandset EC, Bath PM, Boysen G, et al. SCAST Study Group. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011;377(9767):741.

    Google Scholar 

  53. Jauch EC, Saver JL, Adams Jr HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology. Stroke. 2013;44(3):870.

    Article  PubMed  Google Scholar 

  54. Strandgaard S, Paulson OB. Cerebral blood flow and its pathophysiology in hypertension. Am J Hypertens. 1989;2(6 Pt 1):486.

    CAS  PubMed  Google Scholar 

  55. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356(9227):411.

    Article  CAS  PubMed  Google Scholar 

  56. Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002;122:311–28.

    Article  PubMed  Google Scholar 

  57. Estrera AL, Miller III CC, Safi HJ, et al. Outcomes of medical management of acute type B aortic dissection. Circulation. 2006;114:I384–9.

    Article  PubMed  Google Scholar 

  58. Elliott WJ. Clinical features and management of selected hypertensive emergencies. J Clin Hypertens (Greenwich). 2004;6:587–92.

    Article  Google Scholar 

  59. ACOG Committee on Obstetric Practice. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 2002;77:67–75.

    Article  Google Scholar 

  60. Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ. 2003;327:955–60.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  61. Jannet D, Carbonne B, Sebban E, Milliez J. Nicardipine versus metoprolol in the treatment of hypertension during pregnancy: a randomized comparative trial. Obstet Gynecol. 1994;84:354–9.

    CAS  PubMed  Google Scholar 

  62. Carbonne B, Jannet D, Touboul C, Khelifati Y, Milliez J. Nicardipine treatment of hypertension during pregnancy. Obstet Gynecol. 1993;81:908–14.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiology, Baystate Medical Center, Tufts University, 759 Chestnut St, Springfield, MA, 01199, USA

    Jaya Mallidi MD, MHS & Amir S. Lotfi MD

  2. Heart and Vascular Clinical Pharmacy Specialist, Baystate Medical Center, Acute Care Pharmacy Services, 759 Chestnut Street, Springfield, MA, 01199, USA

    C. Gabriela Macías PharmD, BCPS

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  1. Jaya Mallidi MD, MHS
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  2. C. Gabriela Macías PharmD, BCPS
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  3. Amir S. Lotfi MD
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Correspondence to Amir S. Lotfi MD .

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Editors and Affiliations

  1. Center for Drug Evaluation and Research Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, Maryland, USA

    Gowraganahalli Jagadeesh

  2. Pharmacology Unit, AIMST University, Bedong, Malaysia

    Pitchai Balakumar

  3. Center for Drug Evaluation and Research Division of Cardiovascular and Renal Products, US Food and Drug Administration, Silver Spring, Maryland, USA

    Khin Maung-U

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Mallidi, J., Macías, C.G., Lotfi, A.S. (2015). Vasodilators and Management of Hypertensive Emergencies. In: Jagadeesh, G., Balakumar, P., Maung-U, K. (eds) Pathophysiology and Pharmacotherapy of Cardiovascular Disease. Adis, Cham. https://doi.org/10.1007/978-3-319-15961-4_40

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  • DOI: https://doi.org/10.1007/978-3-319-15961-4_40

  • Publisher Name: Adis, Cham

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