p.69 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e182

Table 26.  Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies Class Drug(s) Usual Dose Range Comments CCB—dihydropyridines Nicardipine Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15 mg/h Contraindicated in advanced aortic stenosis; no dose adjustment needed for persons aged ≥65 y. No negative inotropic or chronotropic effects.

Clevidipine Initial 1-2 mg/h, doubling every 90 s until BP approaches target, then increasing by less than double every 5-10 min; maximum dose 21 mg/h; maximum duration 72 h Contraindicated in patients with soybean, soy product, egg, and egg product allergy and in patients with defec­ tive lipid metabolism (eg, pathological hyperlipidemia, lipoid nephrosis [minimal change disease] or acute pan­ creatitis). No negative inotropic or chronotropic effects. Decreased risk of reflex tachycardia.

Vasodilators—nitric-oxide dependent Sodium nitro­ prusside Initial 0.3-0.5 mcg/kg/min; increase in incre­ ments of 0.5 mcg/kg/min every 5 min to achieve BP target; maximum dose 10 mcg/kg/min; du­ ration of treatment as short as possible Due to potency, intra-arterial BP monitoring is recom­ mended to prevent “overshoot.” Lower dose required for older adults. Tachyphylaxis is common with extended use. No negative inotropic or chronotropic effects.

Due to increased mortality risk, should be avoided in acute cerebrovascular disease unless other agents are not available. Use cautiously in pregnancy or older adults. Cyanide toxicity (increased risk in liver dysfunction and chronic kidney disease) and thiocyanate toxicity (in­ creased risk in kidney dysfunction, sCr >3) may occur for infusion rates ≥3 mcg/kg/min and/or duration ≥3 d. Cyanide toxicity and thiocyanate toxicity may present similarly with metabolic acidosis, altered mental status, and cardiac arrhythmia. For either toxicity state, nitro­ prusside should be discontinued and sodium thiosulfate or cyanocobalamin should be administered.

Nitroglycerin Initial 5 mcg/min; increase in increments of 5 mcg/min every 3-5 min to a maximum rate of 200 mcg/min Use only in patients with acute coronary syndrome and/ or acute pulmonary edema. Do not use in volume-deplet­ ed patients. Tachyphylaxis is common with extended use.

Vasodilators—direct Hydralazine Initial 10 mg via slow IV infusion (maximum initial dose 20 mg); repeat every 4-6 h as needed. Adjust rate up to total cumulative dose of 200 mg/24 h BP begins to decrease within 10-30 min, and the fall lasts 2-4 h. Hydralazine is an undesirable first-line agent for acute treatment in most patients due to unpredict­ ability of response and prolonged duration of action. Adrenergic blockers—beta-1 receptor selective antagonist Esmolol Loading dose 500-1000 mcg/kg/min over 1 min followed by a 50-mcg/kg/min infusion. For additional dosing, the bolus dose is repeated, and the infusion increased in 50-mcg/kg/min increments as needed to a maximum of 300 mcg/kg/min Contraindicated in patients with concurrent beta-blocker therapy, bradycardia, or decompensated HF. Monitor for bradycardia.

Higher doses may block beta-2 receptors and impact lung function in reactive airway and obstructive pulmo­ nary disease.

Adrenergic blockers—combined alpha-1 and nonselective beta receptor antagonist Labetalol Initial 0.3- to 1.0-mg/kg dose (maximum 20 mg) slow IV injection at 10-min intervals or 0.4-1.0mg/kg/h IV infusion up to 3 mg/kg/h. Adjust rate up to total cumulative dose of 300 mg/24 h Contraindicated in reactive airway or obstructive pul­ monary disease. Especially useful in hyperadrenergic syndromes. May worsen HF and should not be given in patients with second- or third-degree heart block or bradycardia. Adrenergic blockers— nonselective alpha receptor antagonist Phentolamine IV bolus dose 5 mg. Additional bolus doses every 10 min as needed to lower BP to target. Adjust rate up to total cumulative dose of 50 mg/24 h Used in hypertensive emergencies induced by cat­ echolamine excess (pheochromocytoma, interactions between monoamine oxidase inhibitors and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal). Dopamine-1-receptor selective agonist Fenoldopam Initial 0.1-0.3 mcg/kg/min; may be increased in increments of 0.05-0.1 mcg/kg/min every 15 min until target BP is reached. Maximum infu­ sion rate 1.6 mcg/kg/min Contraindicated in patients at risk of increased intra­ ocular pressure (glaucoma) or intracranial pressure and those with sulfite allergy. ACE inhibitor Enalaprilat Initial 1.25 mg over a 5-min period. Doses can be increased up to 5 mg every 6 h as needed to achieve BP target. Adjust rate up to total cumu­ lative dose of 50 mg/24 h Contraindicated in pregnancy and should not be used in acute MI or bilateral renal artery stenosis.

Mainly useful in hypertensive emergencies associated with high plasma renin activity. Poorly defined dose adjustments for kidney failure and may worsen kidney injury in those with CKD. Relatively slow onset of action (15 min) and unpredictability of BP response.

Modified with permission from Whelton et al.1 Copyright 2018 American College of Cardiology Foundation and American Heart Association, Inc. BP indicates blood pressure; CCB, calcium channel blocker; CKD, chronic kidney disease; HF, heart failure; IV, intravenous; and MI, myocardial infarction.

Downloaded from http://ahajournals.org by on October 7, 2026