Major exceptions to gradual BP lowering over the first day
Acute phase of an ischemic CVA: The BP is usually not treated unless it is greater than 185/110 mmHg in patients whose reperfusion therapy could be an option or greater than 220/120 mm Hg in patients who might not qualify for it. Consider labetalol or nicardipine infusion.
Acute aortic dissection: The SBP should be lowered to 120 mm Hg within 20 minutes, and a target heart rate around 60 beats per minute to reduce aortic shearing forces. Treatment usually requires a beta-blocker and a vasodilator. Options include esmolol, nicardipine, or nitroprusside.
An intracerebral hemorrhage: The goals of therapy are different and depend on the location and surgical approach.
Acute myocardial ischemia: Nitroglycerin is the drug of choice; do not use if the patient has taken phosphodiesterase inhibitors, including sildenafil or tadalafil, within the past 48 hours.
After a suitable period, often 8 to 24 hours, of BP control at a target, oral medications are usually given, and the initial intravenous therapy is tapered and discontinued.