Hypertension crisis management in a Patient with Acute coronary syndrome

In the majority of patients presenting as an emergency with AMI and hypertension without signs of other acute target organ damage, hypertension does not necessarily represent an acute major threat.Treatment should be aimed at relieving ASC symptoms, and protect extending the ischemic by reduction of cardiac demand but it has to be well balanced with potentially risk of coronary perfusion reduction and loss of viable myocardial tissue and cardiogenic shock.In a patient presenting with AMI and hypertension Crisis, the reduction of blood pressure (BP) should not be abrupt and a gradual reduction over a period of 24-48 hours is recommended, so that further myocardial or brain ischemia is avoided.The appropriate treatment should include the initiation of intravenous nitrates, with intravenous labetalol, sodium nitroprusside and/or nicardipine as alternatives, especially in very severe hypertension or hypertensive emergencies.Sublingual nifedipine, which has usually been considered as a firstline drug, should be avoided, in view of the negligible oral absorption and unpredictable hypotensive effects.BP should be reduced to <160/110 mmHg before administration of thrombolysis, although if available, primary angioplasty is an option for reperfusion in patients with high BP and/or the perceived risk of stroke if thrombolysis is unacceptable.Oral or intravenous b-adrenoceptor blockers lower the BP within hours. They also have important anti-ischemic effects, by reducing oxygen demand by 15-30%, so that they should be considered as first-line therapy in patients with myocardial infarction (MI), in the absence of contraindications. Moreover, the b-blockers have antiarrhythmic properties and cause favorable shunting of blood away from non-ischemic to ischemic regions.