Intravenous Antihypertensives Research Articles

Hypertensive emergency: diagnostic and therapeutic strategies

Hypertensive emergencies are life-threatening conditions with end-organ damage caused by sudden increases in blood pressure that exceed 180/110-120 mmHg. Clinical conditions affecting the brain, arteries, retina, kidney and heart are encountered. The brain and cardiovascular system are most commonly affected. Ischemic stroke and acute pulmonary edema are the most common conditions. Some patients may experience end-organ damage independent of blood pressure values. This condition develops due to microangiopathy and deterioration of autoregulation that provides organ blood flow by damaging the vascular endothelium due to increased blood pressure. High blood pressure also increases end-organ damage in a vicious cycle by activating the renin-angiotensin-aldosterone system. This pathophysiology is important in treatment. As a general approach, rapid blood pressure reduction is not desired. Perfusion in end-organs that cannot adapt to autoregulation is impaired, and organ dysfunction deepens with ischemia and necrosis. In the general approach, a 10-20% decrease is targeted in the first hour, while a 5-15% decrease in blood pressure in the remaining 23 hours is sufficient. However, in ischemic stroke, blood pressure control is reduced according to both the treatment and the degree of pressure. If thrombolytic therapy is not to be given, if the blood pressure is not above 220/120 mmHg, no intervention is made. In aortic dissection, the aim is to reduce systolic blood pressure to 100-120 mmHg in a period of 20 minutes. In short, according to the target organ damage, short-acting intravenous antihypertensive drugs that can be treated stepwise and are selected according to the selected target values. In the selection of these drugs, options that may cause secondary damage to organ damage are avoided. Nitroprusside and nitroglycerin, which can increase central pressure, are not preferred primarily in ischemic stroke. Or, in adrenergic crisis, beta blockers can worsen blood pressure without sufficient alpha blockade. It should also be well known that such drugs have important side effects such as severe hypotension and cardiogenic shock.

Insights Into Perioperative Hypertension Management in Europe: Results From a Survey Endorsed by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC)

Perioperative blood pressure control is crucial to ensure organ perfusion and avoid adverse events. However, no consensus on blood pressure targets is available. This study was designed to gain insights into current European perioperative hypertension management practices. Survey research. Online survey. The survey was administered to members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and distributed through the organization's social media. A 22-item questionnaire on the approach to perioperative hypertension control and its pharmacological management. The study included surveys completed between July 1 and October 30, 2023. In total, 339 participants completed the questionnaire; 70% were anesthesiologists, 17% were intensive care physicians, and 12% were cardiac surgeons. More than 50% of respondents declared dealing with perioperative hypertension in 20% to 50% of their surgeries, and most target the 120 to 140 mmHg systolic blood pressure (SBP) range during surgery. Respondents mostly rely on α-adrenoreceptor antagonists (29%), nitrates (23%), and calcium channel blockers (15%) to manage perioperative hypertension. Titratable control was the most appreciated attribute of intravenous antihypertensives. Antihypertensive treatment failure occurred in less than 20% of surgeries, and the highest risk of hypotensive episodes was perceived by participants to be when using nitroglycerin and nitroprusside. Perioperative SBP targets above 140 mmHg are uncommon among respondents, who predominantly target SBP values between 120 and 140 mmHg. The choice of intravenous antihypertensives is based on their manageability and user experience, and titratable control is the most appreciated characteristic.

Standardization of Inpatient Hypertension Management

Introduction: Hypertension is a frequent occurrence during hospitalization and physicians are routinely called to treat hypertensive events despite the asymptomatic nature of patients. Although guidelines about outpatient management of hypertension are available, management strategies for asymptomatic inpatient hypertension are lacking. Without a standardized approach, physicians treat asymptomatic hypertension utilizing inconsistent strategies including intravenous antihypertensives (IVAHs). The use of IVAHs has shown to have adverse effects that are associated with increased morbidity and mortality. Aim: The aim of this project is to standardize the approach to inpatient asymptomatic hypertension and minimize use of IVAHs by 25% in 6 months. Method: Using the IHI Model, a quality improvement project was initiated. Root cause analysis revealed a lack of standard approach to managing asymptomatic hypertension. For PDSA 1, a standardized approach algorithm was created, and residents were educated about criteria for assessing symptoms, any contributing factors/secondary hypertension and if they had a history of hypertension/home meds. For PDSA 2, we expanded education for the nursing staff and provided them with the treatment flowchart. We also included the pharmacy department in our initiative, to form a multidisciplinary approach. For PDSA 3, we included Nurse Practitioners in our education. Results: Prior to PDSA 1, 24 charts were analysed and over 58% of patients (14/24) had received inappropriate IVAHs. Post-intervention, 31 charts were analysed and showed a 32.5 % reduction in IVAH use. Prior to PDSA 2, another 36 patient charts were analysed and 25% of patients had received inappropriate IVAHs. Post-intervention, 21 charts were analysed and showed an 11 % reduction in IVAH use. For PDSA 3, 53% of patients had received inappropriate IVAHs. Which reduced by 11% post intervention. Our post-intervention analysis is ongoing, and although data suggests a promising decrease in the use of inappropriate IVAHs, it has been inconsistent, and sustainability will become a challenge. Conclusion/Next Steps: Our project led to the implementation of a standardized algorithm, thus decreasing inappropriate use of IVAHs and minimizing cost. Management of asymptomatic hypertension in the hospital begins with addressing contributing factors such as pain or anxiety, then reviewing held home medication. With the implementation of a standardized algorithm, we found some success in the reduction of use of IVAHs. Our next steps include implementing the algorithm in the EMR system to have an alert system to clarify when IVAHs are indicated and when other options should be reviewed. We plan to continue our multidisciplinary efforts with the pharmacy and EMR staff along with new admission PA/NP service. Re-education throughout the year will also be implemented to improve sustainability.

Optimizing Delivery Strategies in Eclampsia: A Comprehensive Review on Seizure Management and Birth Methods.

Eclampsia seizure is an always serious and potentially fatal obstetric condition. Safe delivery in women with pregnancies complicated by eclampsia seizures is still one of the greatest challenges in perinatal medicine. Pregnancy should be terminated (childbirth) in the safest and least traumatic way possible. Attempting vaginal delivery can take place only exceptionally, in the event of possibly quick completion of childbirth with a stable state of the mother and the fetus. However, immediate labor via cesarean section is most often recommended. It is essential to maintain left lateral patient positioning during cesarean section. Regional anesthesia can be used only in conscious patients who are free from coagulopathy and from HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome to decrease the risk of aspiration and failed intubation attempts in preeclamptic or eclamptic women. For sudden, unexpected interventions, when a patient arrives at the hospital with an eclampsia seizure without lab results, general anesthesia can be the best option and should be performed by an experienced medical team of anesthesiologists, ready to perform difficult intubation. Magnesium sulfate is the drug that should be used first to stop eclamptic convulsions and prevent their recurrence. Intravenous antihypertensive drugs can stabilize elevated blood pressure (BP), preventing multiorgan failure and recurrent eclampsia seizure, and thus the prevention of maternal death. This article aims to review the management of seizures during pregnancy in women with eclampsia to ensure safe delivery.

Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System.

Asymptomatic severe hypertension (also known as hypertensive urgency) is frequently encountered in the hospital. Previous evidence suggests that management with one-time doses of intravenous (IV) antihypertensives may increase adverse events. Despite this, single-dose treatment remains common in the emergency department and inpatient settings. This quality initiative was launched at New York City Health + Hospitals, the largest safety net hospital system in the United States. The initiative involved two changes to electronic orders for IV hydralazine and IV labetalol: a nonintrusive advisory statement within the order instructions and a mandatory requirement to document the indication for IV antihypertensive use. This initiative took place from November 2021 to October 2022. Of the indications selected for IV antihypertensive orders, 60.7% were for hypertensive emergency, 15.3% were for patients who were strictly NPO, 21.2% were for other, and 2.8% selected more than one indication. For ED-only encounters, aggregate IV hydralazine and IV labetalol orders per 1,000 patient encounters were 2.53 preintervention and 1.55 postintervention (38.7% reduction, p < 0.001). For inpatient encounters, aggregate IV hydralazine and IV labetalol orders per 1,000 patient-days were 18.25 preintervention and 15.81 postintervention (13.4% reduction, p < 0.001). Similar trends were observed for individual orders of IV hydralazine and IV labetalol. There were significant reductions in 7 of the 11 hospitals in inpatient administration of aggregate IV hydralazine and labetalol orders per 1,000 patient-days. This quality improvement initiative successfully reduced unnecessary IV antihypertensive use in an 11-hospital safety net system.

Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults

Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists. To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions. This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization. Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission. The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment. Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history. The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.

Intravenous antihypertensive drugs: a double-edged sword?

aDepartment of Internal Medicine, Zuyderland Medical Centre, Sittard/Heerlen, The Netherlands bDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA Correspondence to Dr Daan J.L. van Twist, Department of Internal Medicine, Zuyderland Medical Centre, P.O. Box 5500, Sittard 6130 MB, The Netherlands. Tel: +31 88 576 6555; fax: +31 88 4597983; e-mail: [email protected] Received 11 November, 2022 Accepted 12 November, 2022

The Burden and In-Hospital Mortality of Stroke Admissions at a Tertiary Level Hospital in Namibia: A Retrospective Cohort Study.

Despite stroke being a leading cause of morbidity and mortality globally, there is a dearth of information on the burden and outcomes of stroke in sub-Saharan Africa and Namibia in particular. A hospital-based, retrospective cohort study was conducted to analyse non-electronic medical records of all consecutive stroke patients who were admitted to one of the highest tertiary-level hospitals in Namibia for 12 months (2019-2020). The primary outcome of the study was to establish the in-hospital mortality, stroke subtypes, and associated complications. In total, 220 patients were included in the study, their mean age was 53 (SD13.8) years, and 55.5% were males. 61.0% had an ischaemic stroke (IS), and 39.0% had a haemorrhagic stroke (HS). The mean age was significantly lower in patients with HS vs. IS (48.2 ± 12.2 vs. 56.1 ± 13.3, p < 0.001). Of the IS patients, the majority (29.0%) had total anterior circulation infarct (TACI), while in the HS group, 34.0% had basal ganglia haemorrhage with or without intraventricular extension. Hypertension (p = 0.015), dyslipidaemia (p = 0.001), alcohol consumption (p = 0.022), and other cardiovascular diseases (p = 0.007) were more prevalent in patients with IS compared to those with HS. The prevalence rate of intravenous thrombolysis was 2.2% in IS and use of intravenous antihypertensives in 25.9% of patients with HS than IS. The in-hospital mortality was 26.4% with complications such as raised ICP, aspiration pneumonia, hydrocephalus, and sepsis significantly high in those that died. Aspiration pneumonia (OR 2.79, 95% CI 1.63-4.76, p < 0.001) and increased ICP (OR 0.30, 95% CI 0.16-057, p < 0.001) were independent predictors of in-hospital mortality on the multivariate analysis. Our findings showed a younger mean age for stroke and mortality rate comparable to other low- to middle-income countries (LMICs). Hypertension and alcohol consumption were the main risk factors for both stroke subtypes, while aspiration pneumonia and raised intracranial pressure predicted in-hospital mortality.

PS-C20-5: WARM IV INFUSION IN HYPERTENSIVE URGENCY

Background: Hypertensive Urgency is defined as marked elevation in systemic blood pressure without any evidence of end organ damage. At present, the condition is managed with intravenous (IV) antihypertensives, of which most common is Sodium Nitroprusside. Aim: In this abstract we explore the possibility of slow IV infusion of warm (37–38oC) Normal Saline along with IV antihypertensives for a better and faster management of Hypertensive Urgency. Content: The slow IV will gradually increase the core body temperature of the patient while preventing fluid overload. Homeostatic regulation of Systemic Blood Pressure is maintained by an intricate network of correlated mechanisms, most of which are temperature dependent. The raised body temperature will be useful to control the Blood Pressure through the following mechanisms - Cardiac Output: reduces as core body temperature increases. Baroreflex: decreased post-synaptic adrenergic vasoconstrictor responses. Chemoreceptors: vascular responsiveness to adrenergic receptor stimulation reduces at higher temperatures. RAAS: Kosunen et al recorded reduced Systolic and Diastolic Blood Pressures at raised body temperatures despite increased levels of Angiotensin II &amp; Aldosterone. Endothelin: Serum concentration of Endothelin-I reduces at higher temperatures. Sweat: Thermal stimulation of sweat gland will help excretion of both salt and water, thus maintaining the sodium balance. VEGF: VEGF-A, a potent vasodilator, is increased during elevated body temperature. However, apart from Blood Pressure, a change in core body temperature causes change in many other parameters as well, which must be considered during this discussion. Coagulation profile - Valeri et al noted no change in in-vivo coagulation states till 100oF Effect on other visceral organs - Internal visceral organs like Liver, Kidneys and Brain were not affected till 100oF Infection Control - Core body temperature close to 100oF has also been found to have a protective role against invasive fungal infections in the ICU Discussion: Though the effects of various antihypertensive drugs to raised body temperatures need to be tested, the above points prove that introducing a protocol of warm IV saline Infusion in patients of Hypertensive Urgency may be extremely beneficial, and also prevent clinical inertia.

Comparison of Intravenous Anti-hypertensives for Preoperative Blood Pressure Control in Hypertensive Disorders of Pregnancy and Effect of Oral Labetalol.

Intravenous hydralazine and labetalol are recommended as first-line anti-hypertensives for controlling severe hypertension in pregnancy. Our study aimed at identifying the most effective drug with minimum side effects for preoperative management of severe hypertension in parturients scheduled for Caesarean delivery (CD). We also studied the effect of these drugs on patients already on oral labetalol in the antenatal period. A prospective observational study was done on 162 hypertensive parturients scheduled to undergo emergency CD who received hydralazine or labetalol in the preoperative period. Demographic data, booking status, hemodynamic data, time taken to reach adequate control of blood pressure (BP), drug efficacy, the incidence of persistent hypertension, adverse effects associated with the drugs, and maternal and fetal outcomes were noted. The time taken for the control of BP was similar with both drugs (p-value = 0.425). The mean number of doses required to achieve target BP was significantly less with hydralazine compared to labetalol (p-value = 0.009). Patients on tablet labetalol in the antenatal period were poorly controlled when put on the same drug intravenously but had better control with hydralazine (p-value = 0.005). The incidence of persistent hypertension was lower in patients treated with hydralazine compared with labetalol (p-value = 0.008). Both drugs took a similar time for BP control. However, hydralazine was more efficacious, produced adequate control of BP in a higher number of patients, and had a lower incidence of persistent hypertension.

Initiation of oral antihypertensives in hospitalized patients with hypertensive urgency: A descriptive study.

In hypertensive urgency, guidelines recommend oral antihypertensives, but with limited guidance on implementation. The objective of this study was to determine whether time to initiation of oral antihypertensives impacts blood pressure (BP) reduction in patients with hypertensive urgency. A descriptive study was conducted of adult hospitalized patients with hypertensive urgency from November 2018 through November 2021. Patients with a systolic BP (SBP) of 180 mm Hg or higher or a diastolic BP (DBP) of 120 mm Hg or higher and receipt of oral antihypertensives within 48 hours of presentation were included. The primary outcome was the percentage change in SBP from baseline at 12 to 24 hours and 24 to 48 hours. Secondary outcomes included the change in DBP and mean arterial pressure (MAP), time to 3 consecutive goal SBP readings, continuation of home oral antihypertensives, administration of intravenous (IV) antihypertensives, and length of stay (LOS). Patients were stratified by quartile (Q1 through Q4) based on time to first oral antihypertensive. A total of 220 patients were included. A significant difference in SBP was observed among the quartiles, due to the greater sustained SBP reduction in Q1 at 12 to 24 hours and 24 to 48 hours (median [interquartile range, IQR], 22.9% [13.1%-30.5%] and 22.5% [IQR, 15.8%-32.9%] reduction, respectively). There were also reductions in DBP and MAP, with Q1 consistently having larger reductions than Q4. Patients in Q1 had 3 consecutive goal SBP readings earlier than those in the other quartiles (median [IQR], 13.1 [7.0-21.5] hours). Continuation of home medications, number of IV antihypertensives, and LOS did not differ among the quartiles. In this analysis, earlier administration of oral antihypertensives was associated with a larger sustained reduction in SBP.

Effect of intravenous antihypertensives on outcomes of severe hypertension in hospitalized patients without acute target organ damage.

Treatment of severe inpatient hypertension (HTN) that develops during hospitalization is not informed by guidelines. Intravenous (i.v.) antihypertensives are used to manage severe HTN even in the absence of acute target organ damage; however they may result in unpredictable blood pressure (BP) reduction and cardiovascular events. Our goal was to assess the association between i.v. antihypertensives and clinical outcomes in this population. This is a multihospital retrospective study of adults admitted for reasons other than HTN who develop severe HTN during hospitalization without acute target end organ damage. We defined severe HTN as BP elevation of systolic >180 or diastolic >110 mmHg. Treatment was defined as receiving i.v. antihypertensives within 3 h of BP elevation. We used overlap propensity score weighted Cox models to study the association between treatment and clinical outcomes during index hospitalization. Of 224 265 unique, nonintensive care unit hospitalizations, 20 383 (9%) developed severe HTN, of which 5% received i.v. antihypertensives and 79% were untreated within 3 h of severe BP elevation. In the overlap propensity weighted population, patients who received i.v. antihypertensives were more likely to develop myocardial injury (5.9% in treated versus 3.6% in untreated; hazard ratio [HR]: 1.6 [1.13, 2.24]). Treatment was not associated with increased risk of stroke (HR: 0.7 [0.3, 1.62]), acute kidney injury (HR: 0.97 [0.81, 1.17]), or death (HR: 0.86 [0.49, 1.51]). Intravenous antihypertensives were associated with increased risk of myocardial injury in patients who develop severe HTN during hospitalization. These results suggest that i.v. antihypertensives should be used with caution in patients without acute target organ damage.

Clinical characteristics and prognosis of patients with very severe acute hypertension visiting the emergency department

BackgroundData regarding very severe acute hypertension, a serious problem in emergency departments (EDs), are scarce. We investigated the clinical characteristics, practice patterns, and long-term prognoses of patients presenting to the ED with very severe acute hypertension.MethodsCross-sectional study data were obtained from a single regional emergency medical center, including patients aged ≥ 18 years who were admitted to the ED between January 2016 and December 2019 for very severe acute hypertension, which was defined as systolic blood pressure of > 220 mmHg and/or diastolic blood pressure of > 120 mmHg. The patients were classified into two groups based on the presence or absence of hypertension-mediated organ damage (HMOD).ResultsAmong 1,391 patients with very severe acute hypertension in the ED, half of the them (50.2%) had a previous medical history of hypertension, and 547 (39.3%) had acute HMOD. The overall 3-month, 1-year, and 3-year mortality rates were 5.2%, 11.9%, and 17.3%, respectively. In particular, patients with HMOD had a significantly higher mortality rate at each time point than those without HMOD. Among patients with HMOD, acute ischemic stroke was the most common (28.7%). Moreover, intravenous antihypertensive drugs were significantly more prescribed in patients with HMOD than in those without HMOD (79.0% vs. 22.2%, P < 0.001), but there were no differences in oral antihypertensive drugs between the two groups.ConclusionsPatients with very severe acute hypertension had poor long-term clinical prognoses. Clinicians should be continuously monitoring and providing appropriate treatment and close follow-up for patients with very severe acute hypertension.

P.120 Contrast induced encephalopathy following endovascular therapy for the treatment of cerebrovascular disease

Background: Contrast induced encephalopathy (CIE) is an underrecognized, adverse effect of contrast administration during endovascular procedures. A paucity of literature exists regarding CIE following treatment of cerebrovascular disease. As such, we sought to describe our institutional experience with this entity. Methods: We searched our neurovascular database for instances of CIE following endovascular therapy for cerebrovascular disease. We extracted patient data, including demographics, comorbidities, procedural data, symptoms, radiological findings, and treatment. Informed consent was obtained in all cases. Data was analyzed using descriptive statistics. Results: Two patients underwent coiling of cerebral aneurysms; four were treated for ischemic stroke (thromboembolism or large artery atherosclerosis). Mean age was 67.2 years. Risk factors for microvascular dysfunction were identified for most patients: hypertension (100%), obesity (83%), dyslipidemia (83%), prior stroke (83%), renal disease (80%), and connective tissue disorders (33%). Mean operative duration: 284.5 minutes. Mean contrast volume: 285.7 mL. Decreased level of consciousness and lateralizing neurological deficits were the most common CIE-related symptoms. Treatments included intravenous fluids, corticosteroids, and anti-hypertensives. Radiographic findings included effaced cortical sulci, parenchymal edema, and cortical/subarachnoid contrast enhancement. Conclusions: Here, we describe our institutional experience with CIE following endovascular therapy for cerebrovascular disease. We hypothesize that CIE may be facilitated by pre-existing microvascular pathology.

Acute bilateral ureteropelvic junction obstruction as a rare cause of hypertensive crisis: a case report

BackgroundBilateral ureteropelvic junction obstruction is a common cause of secondary hypertension in the pediatric population, often due to congenital malformation. On the other hand, it is less frequently encountered in the adult population and is usually due to an acquired condition, most commonly by a bilaterally obstructing nephrolithiasis causing hydronephrosis and subsequent hypertension. The aim of this study was to investigate and highlight the underlying mechanisms by which acute bilateral ureteropelvic junction obstruction causes hypertensive crisis and why early detection and prompt treatment are necessary to mitigate the effects of elevated blood pressure on target organs.Case presentationA 41-year-old African American man with hypertensive cardiomyopathy presented with anuria. He was found to have elevated blood pressure with evidence of target organ damage on laboratory examination, demonstrated by sudden elevation of his serum creatinine level. He was initially treated with oral and intravenous antihypertensives, with minimal improvement. The work-up was unremarkable apart from the imaging finding of acute bilateral ureteropelvic junction obstruction from obstructing nephrolithiasis causing hydronephrosis. Bilateral ureteral stents were placed for decompression, with resolution of the hypertensive crisis and improvement of renal function.ConclusionThis case highlights the importance of prompt diagnosis and treatment of underlying acute bilateral ureteropelvic junction obstruction to mitigate the deleterious effects of sudden blood pressure elevation on target organs.

An Unusual Case of Malignant Hypertension and Stress Cardiomyopathy

A 39-year-old man with chronic hypertension presented with perioperative malignant hypertension while undergoing induction for elective surgery. He was treated with intravenous antihypertensives. He reported several years of episodic chest pain, palpitations, and diaphoresis. Transthoracic echocardiogram demonstrated new-onset cardiomyopathy. Urinary and serum catecholamines were measured and the pattern of catecholamine levels suggested an extra-adrenal source. Computed tomography of the abdomen showed a contrast-enhancing mass in the bladder suspicious for metastatic paraganglioma. The patient had surgical resection with substantial improvement in his hypertension. The presence of labile hypertension and acute cardiomyopathy precipitated by stress should prompt evaluation for a catecholamine-producing tumor and appropriate genetic testing.

The impact of fetal growth restriction in diagnosing preeclampsia on the severity of maternal features.

We aimed to assess the impact of fetal growth restriction (FGR) as a diagnostic criterion for preeclampsia (PE) on the severity of maternal preeclamptic features by comparing it with other diagnostic criteria for PE, maternal organ dysfunction. We performed a retrospective cohort study of singleton pregnancies. Based on the status at diagnosis, PE cases preceded by FGR without maternal organ dysfunction (Group F; n = 28) and those preceded by maternal organ dysfunction without FGR (Group M; n = 87) were analyzed. Group F had an earlier PE diagnosis (32.5 ± 4.9 vs. 36.7 ± 3.5 weeks, p < 0.01) and delivery (33.7 ± 4.5 vs. 37.5 ± 3.1 weeks, p < 0.01) than Group M. No significant differences in maternal morbidities were observed between the groups, including severe hypertension (75.0 vs. 60.0%), need for intravenous antihypertensives (42.9 vs. 48.3%) or magnesium sulfate (60.7 vs. 54.5%), or a composite of major maternal complications (17.9 vs. 21.8%). When limited to early-onset PE diagnosed before 34 weeks of gestation (17 and 17 cases in Group F and M, respectively), the frequencies of maternal morbidities (severe hypertension: 70.6 vs. 52.9%, intravenous antihypertensives: 35.3 vs. 35.3%, magnesium sulfate: 58.8 vs. 47.1%, major complications: 29.4 vs. 23.5%) and the duration from diagnosis until delivery (11.2 ± 14.7 vs. 16.5 ± 21.7 days) were comparable between two groups. Our results suggest that the presence of FGR on PE diagnosis is associated with the development of severe maternal symptoms as much as that of maternal organ dysfunction at diagnosis, and it may be reasonable to include FGR in PE diagnostic criteria.

Preeclampsia and Related Problems.

Hypertensive disorders of pregnancy can be classified as chronic hypertension (present before pregnancy), gestational hypertension (onset after 20 weeks of pregnancy), and preeclampsia (onset after 20 weeks of pregnancy, along with proteinuria and other organ dysfunction). Preeclampsia and related disorders are a major cause of maternal and fetal morbidity and mortality. Preeclampsia is believed to result from an angiogenic imbalance in the placenta circulation. Antenatal screening and early diagnosis may help improve outcomes. Severe preeclampsia is characterized by SBP ≥160 mm Hg, or DBP ≥110 mm Hg, thrombocytopenia (platelet count <100 × 109/L), abnormal liver function, serum creatinine >1.1 mg/dL, or a doubling of the serum creatinine concentration in the absence of other renal diseases, disseminated intravascular coagulation, pulmonary edema, new-onset headache, or visual disturbances. Severe preeclampsia or eclampsia (preeclampsia with seizures) needs ICU management and is the main cause of morbidity and mortality. Severe hypertension can also result in life-threatening intracranial hemorrhage. Blood pressure control, seizure prevention, and appropriate timing of delivery are the cornerstones of the management of preeclampsia. Besides intravenous antihypertensive drugs, intravenous magnesium sulfate is the drug of choice to prevent or treat seizures, when preparing for urgent delivery. At present, delivery remains the most effective treatment for preeclampsia, and organ dysfunction rapidly recovers after delivery. Novel therapeutic interventions are under development to reduce complications.How to cite this articleNarkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021;25(Suppl 3):S261–S266.

Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review.

Acute blood pressure (BP) management in neurologic patients is paramount. Different neurologic emergencies dictate various BP goals. There remains a lack of literature determining the optimal BP regimen regarding safety and efficacy. The objective of this study was to identify which intravenous antihypertensive is the most effective and safest for acute BP management in neurologic emergencies. Ovid EBM (Evidence Based Medicine)Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection were searched from inception to August 2020. Randomized controlled trials or comparative observational studies that evaluated clevidipine, nicardipine, labetalol, esmolol, or nitroprusside for acute neurologic emergencies were included. Outcomes of interest included mortality, functional outcome, BP variability, time to goal BP, time within goal BP, incidence of hypotension, and need for rescue antihypertensives. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the degree of certainty in the evidence available. A total of 3878 titles and abstracts were screened, and 183 articles were selected for full-text review. Ten studies met the inclusion criteria; however, the significant heterogeneity and very low quality of studies precluded a meta-analysis. All studies included nicardipine. Five studies compared nicardipine with labetalol, three studies compared nicardipine with clevidipine, and two studies compared nicardipine with nitroprusside. Compared with labetalol, nicardipine appears to reach goal BP faster, have less BP variability, and need less rescue antihypertensives. Compared with clevidipine, nicardipine appears to reach goal BP goal slower. Lastly, nicardipine appears to be similar for BP-related outcomes when compared with nitroprusside; however, nitroprusside may be associated with increased mortality. The confidence in the evidence available for all the outcomes was deemed very low. Because of the very low quality of evidence, an optimal BP agent for the treatment of patients with neurologic emergencies was unable to be determined. Future randomized controlled trials are needed to compare the most promising agents.