| Acute myocardial infarction, early treatment10-13 | Esmolol: Load with 500 mcg/kg intravenous over 1 minute, then infuse 50 mcg/kg/min for 4 minutes. If inadequate response after 5 minutes, continue intravenous infusion at 50 mcg/kg/min, or may increase rate by increments of 50 mcg/kg/min at intervals of > 4 minutes, up to a maximum of 300 mcg/kg/min or until systolic blood pressure is less than 90 mm Hg. Start therapy with an oral beta-adrenergic blocker as soon as possible.
Metoprolol: 5 mg rapid intravenous push, then repeat dose every 2 to 5 minutes for a total of 3 doses (15 mg total dose). Within 15 minutes of the last intravenous dose, start metoprolol 25 to 50 mg orally every 6 hours for 48 hours, then increase to 100 mg orally twice daily thereafter. | Consider conserving intravenous beta-adrenergic blockers for those patients most likely to benefit from their use.
Dilute esmolol to a final concentration of < 10 mg/mL before infusion (ie, 2.5 g/250 mL or 5 g/500 mL).
Discontinue intravenous beta-adrenergic blockers for heart rate < 50 beats per minute or systolic blood pressure < 90 mm Hg.
Begin oral therapy only in patients who tolerate intravenous beta-adrenergic blockers. |
| Unstable angina or non-ST-segment elevation myocardial infarction in patients at high risk for ischemic events10-15 | Esmolol: Load with 500 mcg/kg intravenous over 2 to 3 minutes, then start continuous infusion at 50 mcg/kg/min. Increase infusion rate by 50 mcg/kg/min every 10 to 15 minutes as needed to reach target heart rate, up to a maximum of 300 mcg/kg/min.
Metoprolol: 5 mg intravenous push over 1 to 2 minutes, then repeat dose every 5 minutes for a total of 3 doses (15 mg total dose). Within 15 minutes of the last intravenous dose, start metoprolol 25 to 50 mg orally every 6 hour for 48 hours, then increase to 100 mg orally twice daily thereafter.
Propranolol: Give 0.5 to 1 mg intravenous initially. Within 1 to 2 hours of the intravenous loading dose, start propranolol 40 to 80 mg orally every 6 to 8 hours.
| Consider conserving intravenous beta-adrenergic blockers for those patients most likely to benefit from their use.
Dilute esmolol to a final concentration of < 10 mg/mL before infusion (ie, 2.5 g/250 mL or 5 g/500 mL).
Target resting heart rate is 50 to 60 beats per minute.
Discontinue intravenous beta-adrenergic blockers for heart rate < 50 beats per minute or systolic blood pressure < 90 mm Hg.
Begin oral therapy only in patients who tolerate intravenous beta-adrenergic blockers. |
| Hypertensive emergency10-11,16 | Enalaprilat: 1.25 to 5 mg slow intravenous push every 6 hours. In patients taking diuretics, give 0.625 mg initially; may increase to 1.25 mg for second dose if needed.
Esmolol: Load with 500 mcg/kg intravenous over 1 minute, then infuse 50 to 100 mcg/kg/min for 4 minutes. May repeat loading dose or increase infusion rate to a maximum of 300 mcg/kg/min.
Hydralazine: 10 to 20 mg intravenous or intramuscular. May repeat every 4 to 6 hours as needed. May increase to 40 mg/dose if needed.
Labetalol: 10 to 20 mg slow intravenous push, then 40 to 80 mg intravenous every 10 minutes as needed to reduce blood pressure, up to a maximum dose of 300 mg. May also give 0.5 to 2 mg/min by continuous intravenous infusion, up to a maximum dose of 300 mg.
Metoprolol: 1.25 to 5 mg intravenous every 6 to 12 hours. | In stable patients, the goal is to reduce blood pressure 25% within 1 hour, then further reduce to 160/100 to 160/110 mm Hg in the next 2 to 6 hours.
The hypotensive effects of intramuscular hydralazine are delayed compared with intravenous administration.
Hydralazine injection may have unpredictable and prolonged antihypertensive effects.
Dilute esmolol to a final concentration of < 10 mg/mL before infusion (ie, 2.5 g/250 mL or 5 g/500 mL).
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