Intravenous Antihypertensive Drugs for Treatment of Hypertensive Emergencies in Patients With Selected Comorbidities Comorbidity Preferred Drug(s)* Comments Acute aortic dissection Esmolol, labetalol Requires rapid lowering of SBP to 120 mm Hg.Beta blockade should precede vasodilator (eg, nicardipine or nitroprusside) administration, if needed for BP control or to prevent reflex tachycardia or inotropic effect; SBP 120 mm Hg should be achieved within 20 min. Acute pulmonary edema Clevidipine, nitroglycerin, nitroprusside Beta blockers contraindicated. Acute coronary syndromes Esmolol, labetalol, nicardipine, nitroglycerin Nitrates given in the presence of PDE-5 inhibitors may induce profound hypotension. Contraindications to beta blockers include moderate-to-severe LV failure with pulmonary edema, bradycardia (<60 bpm), hypotension (SBP <100 mm Hg), poor peripheral perfusion, second- or third-degree heart block, and reactive airways disease. Acute renal failure Clevidipine, fenoldopam, nicardipine N/A Eclampsia or preeclampsia Hydralazine, labetalol, nicardipine Requires rapid BP lowering.ACE inhibitors, ARBs, renin inhibitors, and nitroprusside contraindicated. Perioperative hypertension (BP 160/90 mm Hg or SBP elevation 20% of the preoperative value that persists for Clevidipine, esmolol, nicardipine, nitroglycerin Intraoperative hypertension is most frequently seen during anesthesia induction and airway manipulation. Acute sympathetic discharge or catecholamine excess states (eg, pheochromocytoma, post-carotid endarterectomy status) Clevidipine, nicardipine, phentolamine Requires rapid lowering of BP. Acute ICH Section 9.4.1 Section 9.4.1 Acute ischemic stroke Section 9.4.2 Section 9.4.2 *Agents are listed in alphabetical order, not in order of preference. Agent of choice for acute coronary syndromes. ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; bpm, beats per minute; ICH, intracerebral hemorrhage; LV, left ventricular; PDE-5, phosphodiesterase type-5; and SBP, systolic blood pressure. Whelton et al 2017 High Blood Pressure Clinical Practice Guideline e69 demonstrated a reduction in dementia incidence, with 2 of these 4 demonstrating statistical significance (746-751). 