Clevidipine for Nicardipine Resistant Hypertension in Neurocritically Ill Patients

Acute hypertension is common in acute brain injuries and contributes to increased morbidity and mortality. The optimal agent to manage acute hypertension is unclear, though most critically ill patients in the Neuro Intensive Care Unit (Neuro ICU) are managed with nicardipine as a first line agent. If hypertension is inadequately controlled despite the maximal dose of nicardipine, few other agents exist that are both safe and efficacious. Clevidipine may be an optimal agent for nicardipine refractory hypertension. This retrospective cohort study included acute brain injured patients that were unable to achieve blood pressure goals despite maximal doses of nicardipine and were switched to clevidipine. The primary outcome was to evaluate the percentage of patients that achieved systolic blood pressure goals within 1 hour of clevidipine initiation. Secondary outcomes included hypotension, need for vasopressors, and development of tachycardia. Additional outcomes included duration of antihypertensive infusions and administration of as-needed hypertension medications. Out of 410 screened patients, 66 were included (median age 53.7 years, 43.9% female). Patients were at maximum nicardipine dose (15 mg/hr) when clevidipine was initiated in 91% of cases. Among those included, 77.3% of patients were unable to achieve goal blood pressure while on nicardipine therapy. Goal blood pressure was able to be achieved within 1 hour in 84.8% of patients receiving clevidipine. Adverse effects were minimal, with only 4 (6%) patients experiencing hypotension and 4 (6%) patients developing tachycardia within 12hrs of clevidipine initiation. The median duration of clevidipine infusion was 23.9 hours. Clevidipine appears to be an effective, safe alternative agent in patients that are unable to achieve blood pressure goals with nicardipine infusion. Future prospective, multicenter studies are needed to validate these findings and assess long-term neurological outcomes. Clinicians managing nicardipine-refractory hypertension in neurocritically ill patients may consider clevidipine as a structured second-line option pending such evidence.