Version June 2024
| Drug | Drug class | Dose range | Onset of action | Duration of action | Adverse effects* | Role¶ |
| Anti-impulse therapy | ||||||
| Esmolol* | Beta1-selective adrenergic receptor blockade | 500 mcg/kg IV loading dose over one minute, then initiate IV infusion at 25 to 50 mcg/kg per minute; titrate incrementally up to maximum of 300 mcg/kg per minute. Prior to each upward dose titration, a re-bolus should be given. | 1 to 2 minutes. | 10 to 30 minutes. | Nausea, flushing, bronchospasm, bradycardia, first-degree heart block, infusion site pain; half-life prolonged in setting of anemia. Vesicant. Infusion volume may be excessive; available concentrations include 10 mg/mL and 20 mg/mL (premixed). | Extremely short half-life and ability to rapidly titrate to effect are advantages over other IV beta-blockers in acute setting because hemodynamic changes can occur so rapidly and to assess effect in patients who may be intolerant of beta-blockade (eg, due to airway disease or heart failure). Rapidly cleared by red blood cell esterases (ie, clearance is not dependent on kidney or hepatic function). Avoid use in decompensated heart failure. |
| Labetalol | Selective blockade of postsynaptic alpha1-adrenergic and non-selective blockade for beta-adrenergic receptors | Initial bolus of 20 mg IV followed by 20 to 80 mg IV boluses every 10 minutes (maximum 300 mg)
| 2 to 5 minutes. | 2 to 6 or more h(dose dependent). | Nausea/vomiting, paresthesias (eg, scalp tingling), bronchospasm, dizziness, nausea, bradycardia, first-degree heart block. | Combined alpha and beta-blockade may enable management with single agent. Avoid use in acute decompensated heart failure. Use cautiously in obstructive or reactive airway. |
| Metoprolol | Beta1-selective adrenergic receptor blockade | 5 mg IV bolus every 5 minutes for three doses; additional IV doses of 5 to 10 mg every 4 to 6 hours as needed. | 20 minutes. | 5 to 8 hours. | Refer to labetalol. | Avoid use in decompensated heart failure. |
| Diltiazem | Non-dihydropyridine calcium channel blocker | Initial bolus of 0.25 to 0.35 mg/kg IV followed by continuous infusion of 5 to 20 mg/hour. | 1 to 3 minutes. | 1 to 3 hours (bolus). 0.5 to 10 hours (after discontinuation of infusion). | Dizziness, nausea, bradycardia, first-degree heart block. | Alternative anti-impulse therapy in patients who do not tolerate beta-blockade. Avoid use in decompensated heart failure. |
| Verapamil | Non-dihydropyridine calcium channel blocker | 5 to 10 mg IV; may repeat after 5 to 10 minutes. | 3 to 5 minutes. | 0.5 to 6 hours. | Refer to diltiazem. | Alternative anti-impulse therapy in patients who do not tolerate beta-blockade. Avoid use in acute decompensated heart failure. |
| Vasodilators¶ | ||||||
| First-line | ||||||
| Nitroprusside | Direct relaxation of vascular smooth muscle | Initially 0.25 to 0.5 mcg/kg per minute as IV infusion titrated to a maximum of 10 mcg/kg per minute.Δ | Immediate. | 1 to 10 minutes. | Elevated intracranial pressure, decreased cerebral blood flow, reduced coronary blood flow in CAD, cyanide and thiocyanate toxicity, nausea, vomiting, muscle spasm, flushing, sweating. | Add-on to beta-blockade for additional lowering of SBP if needed. Rapidly titratable. Continuous monitoring using an intra-arterial cannula from the arm with the highest auscultatory pressure is warranted. |
| Nicardipine* | Calcium channel blocker | Initially 5 mg/hour as IV infusion, increasing every 5 minutes by 2.5 mg/hour to a maximum of 15 mg/hour. | 5 to 15 minutes. | 0.5 to ≤8 minutes. | Tachycardia, headache, dizziness, nausea, flushing, local phlebitis, edema. Infusion volume may be excessive; available concentrations include 0.1 and 0.2 mg/mL (premixed). | Add-on to beta-blockade for additional lowering of SBP if needed. |
| Second-line | ||||||
| Clevidipine | Calcium channel blocker | Initially 1 to 2 mg/hour as IV infusion with rapid titration. Most patients respond to 4 to 6 mg/hour and are treated with doses of 16 mg/hour or less. Delivered in lipid emulsion. 1000 mL maximum per 24 hours (which is equivalent to 21 mg/hour) due to lipid load. | 2 to 4 minutes. | 5 to 15 minutes. | Atrial fibrillation, nausea, lipid contains potential allergens (eg, soy, egg). | Add-on to beta-blockade for additional lowering of SBP if needed. Rapidly cleared by plasma esterases (ie, clearance is not dependent on kidney or hepatic function). |
| Nitroglycerin (glyceryl trinitrate) | Direct relaxation of vascular smooth muscle | 5 to 200 mcg/minute as IV infusion. | 2 to 5 minutes. | 5 to 10 minutes. | Hypoxemia, tachycardia (reflex sympathetic activation), headache, vomiting, flushing, methemoglobinemia, tolerance with prolonged use. | Potential add-on to beta-blockade if needed for additional blood pressure lowering. May be useful in patients with coronary ischemia or acute pulmonary edema. |
| Enalaprilat | Angiotensin-converting enzyme (ACE) inhibitor | 1.25 to 5 mg IV every 6 hours. | 15 to 30 minutes. | Approximately 6 hours. | Precipitous fall in pressure in high-renin states; variable response, headache, dizziness. | Potential add-on to beta-blockade for additional lowering of SBP if needed. Due to slow onset, variable response, and long duration of effect, rarely used. Avoid use in acute myocardial infarction, kidney impairment, or pregnancy. |
| Fenoldopam | Agonist for D1-like dopamine receptors; binds with moderate affinity to alpha2-adrenoceptors | Initially 0.1 mcg/kg per minute◊ as IV infusion titrated to a maximum of 1.6 mcg/kg per minute. | 5 to 10 minutes. | 1 to 4 hours. | Tachycardia, headache, nausea, flushing, increased serum creatinine. | Potential add-on to beta-blockade for additional lowering of SBP if needed. Use caution or avoid with glaucoma or increased intracranial pressure. |
IV: intravenous; CAD: coronary artery disease; SBP: systolic blood pressure.
* Maximize infusion concentration to reduce volume overload during administration.
¶ Vasodilator therapy without prior beta blockade may cause reflex tachycardia and increased aortic shear stress. In the acute setting, because hemodynamic changes can occur so quickly, agents with a longer half-life that cannot be stopped or reversed quickly are generally avoided. The use of non-selective beta blockers alone in patients with acute cocaine intoxication may lead to unopposed alpha stimulation worsening hypertension. Refer to UpToDate topics discussing management of acute aortic syndromes, including aortic dissection.
Δ A maximum dose of 10 mcg/kg per minute for brief periods (up to 10 minutes) has been used when warranted; to minimize risk of cyanide toxicity, infusion duration should be as short as possible and not exceed 2 mcg/kg per minute. Patients who receive higher doses (ie, >500 mcg/kg at a rate exceeding 2 mcg/kg per minute) should receive sodium thiosulfate infusion to avoid cyanide toxicity.
◊ Initial fenoldopam doses in range of 0.01 to 0.3 mcg/kg per minute have been described.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
