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New approaches for the treatment of hypertensive urgencies and emergencies.

Despite widespread recognition of hypertension, acute lowering of blood pressure is indicated in certain clinical situations constituting hypertensive emergencies and urgencies. In this brief discussion, certain new aspects in the management of hypertensive crises will be discussed. In general, hypertensive crises can be divided into three classes. Hypertensive emergencies pose a significant and immediate threat to the patient's life, cardiovascular, neurologic and/or renal systems. Immediate blood pressure reduction in "hours" is necessary in hypertensive emergencies. Hypertensive urgencies are situations where the patient's elevated blood pressure ultimately poses a serious risk to the patient if it is not treated aggressively. Examples of hypertensive urgencies are shown in Table 1. In the last category, the blood pressure requires gradual reduction primarily to prevent longterm sequelae of untreated hypertension. True hypertensive emergencies such as hypertension with acute heart failure and pulmonary edema or hypertensive encephalopathy still require initial blood pressure control with appropriate therapy and intensive care monitoring with intra-arterial blood pressure monitoring. Therapeutic choices available for the treatment of hypertensive crises are shown in Table 2. This discussion will be limited to the use of new therapeutic agents. Labetalol is a drug that possesses both alpha-blocking and beta-blocking properties and effectively lowers the blood pressure when given parenterally or by oral route.13 The parenteral form can be given either as a bolus or as a continuous infusion. In patients with low output heart failure, labetalol decreases peripheral vascular resistance without depressing the cardiac output. Continuous infusion of labetalol can be given as a 2 mg/min infusion with a maximum dose of150 mg. A blood pressure response can usually be seen in 15 minutes. Alternatively, the infusion can be started at