Management Of Hypertensive Emergencies Research Articles

HYPERTENSIVE CRISES: HYPERTENSIVE EMERGENCY AND CRISIS MANAGEMENT DURING ANESTHESIA

Introduction: hypertensive crisis is characterized by an acute and massive increase in blood pressure. Hypertensive crises encompass several clinical situations with different severity and prognosis, including hypertensive urgency and hypertensive emergency. The difference between the latter depends on whether the situation is life-threatening for the affected individual. Objective: to detail current information related to hypertensive crises, especially hypertensive emergency, definition, differentiation, etiology, epidemiology, pathophysiology, histology, clinical history, physical examination, management, differential diagnosis, prognosis and complications. Methodology: a total of 28 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 15 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hypertensive crises, hypertensive emergencies, hypertensive emergencies, arterial hypertension. Results: approximately 1-2% of adults with hypertension suffer hypertensive crises. Multiple case series show that short-term treatment of hypertensive emergencies has good results; however, long-term results are unknown. The main drawback is that follow-up of individuals is lost and the medication regimen is frequently modified. Untreated hypertensive emergencies have very high morbidity and mortality and if the patient does not receive adequate education about the severity of hypertension, this trend is likely to continue. Conclusions: given the high prevalence of hypertension, it is crucial that health care professionals are able to differentiate between hypertensive emergencies and hypertensive emergencies to provide appropriate and timely treatment. Rapid blood pressure reduction is critical in the treatment of hypertensive emergencies. The choice of medications should consider both efficacy and safety to avoid further complications. A detailed clinical evaluation can help identify the underlying cause and guide treatment, highlighting the importance of an individualized approach. Lack of timely treatment can lead to severe consequences, emphasizing the need for proper management in critical situations. Constant training in the management of hypertensive emergencies is essential to reduce the morbidity and mortality associated with this condition.The management of hypertension during anesthesia is critical, as its prompt detection and control are fundamental to prevent serious complications. Despite the lack of specific criteria to suspend surgery in hypertensive patients, it is essential to evaluate each case individually, prioritizing target organ damage over blood pressure levels. KEY WORDS: crisis, emergency, urgency, hypertension.

Diagnosis and Management of Hypertensive Emergency in a Patient With Generalized Anxiety Disorder.

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

Management of Hypertensive Crises in Children: A Review of the Recent Literature.

Hypertensive emergency is a life-threatening condition associated with severe hypertension and organ damage, such as neurological, renal or cardiac dysfunction. The most recent guidelines on pediatric hypertension, the 2016 European guidelines and the 2017 American guidelines, provide recommendations on the management of hypertensive emergencies, however in pediatric age robust literature is lacking and the available evidence often derives from studies conducted in adults. We reviewed PubMed and Cochrane Library from January 2017 to July 2021, using the following search terms: “hypertension” AND “treatment” AND (“emergency” OR “urgency”) to identify the studies. Five studies were analyzed, according to our including criteria. According to the articles reviewed in this work, beta-blockers seem to be safe and effective in hypertensive crises, more than sodium nitroprusside, although limited data are available. Indeed, calcium-channel blockers seem to be effective and safe, in particular the use of clevidipine during the neonatal age, although limited studies are available. However, further studies should be warranted to define a univocal approach to pediatric hypertensive emergencies.

Effectiveness and safety of urapidil in patients with hypertensive crisis complicated with acute coronary syndrome

The objective was to evaluate both the effectiveness and safety of urapidil (Ebrantil) in management of hypertensive emergencies in patients with acute coronary syndrome at the hospital stage and its comparison with other antihypertensive drugs. Systolic, diastolic pressure, and heart rate in 33 patients who were treated with urapidil at different dosage regimen (bolus from 12.5 to 50 mg) and 33 patients treated with other hypertensive drugs. The groups were selected as case — control and compared by the main clinical values. During the hospital treatment the clinical outcomes, rate and effectiveness in achieving target blood pressure were assessed. Urapidil (Ebrantil) use is more effective and safe in management of HE complicated with acute coronary syndome compared with other antihypertensive drugs.

Management of hypertensive emergencies and urgencies: narrative review.

Hypertensive emergencies are distinguished from hypertensive urgencies by the presence of clinical or laboratory target organ damage. The most common forms of target organ damage in developed countries are pulmonary oedema/heart failure, acute coronary syndrome, ischaemic and haemorrhagic stroke. In the absence of randomised trials, it is inevitable that guideline writers differ slightly regarding the speed and extent to which blood pressure should be lowered acutely. An appreciation of cerebral autoregulation is key and should underpin treatment decisions. Hypertensive emergencies, with the notable exception of uncomplicated malignant hypertension, require intravenous antihypertensive medication which is most safely given in high dependency or intensive care settings. Patients with hypertensive urgency are often treated with medications that lower their blood pressure acutely, although there is no evidence to support this practice. This article aims to review current guidelines and recommendations, and to provide user friendly management strategies for the general physician.

280 Arterial Line versus Noninvasive Blood Pressure Monitoring in Hypertensive Emergencies

Blood pressure (BP) monitoring is important for managing patients with hypertensive emergencies. Management of such conditions often involves relatively narrow and specific blood pressure windows. While invasive arterial blood pressure (IABP) monitoring is considered the gold standard method of BP measurement, its usefulness is unclear. Although previous studies demonstrated differences between IABP and NIBP values, few had assessed whether these differences would affect clinical management. Our study aimed to determine whether the difference between NIBP and IABP would change BP management in patients with hypertensive emergencies. This was a prospective observational study of adult patients with any hypertensive emergency admitted to the Critical Care Resuscitation Unit (CCRU) at a quaternary academic center from January 2019—April 2021. We included consecutive patients with diagnoses of ischemic stroke, acute aortic disease, spontaneous intracranial hemorrhage (sICH), etc, and who required arterial monitoring. We excluded patients who had hypertensive diagnoses but required vasopressors due to overtreatment of anti-hypertensive medications or those who had arterial catheters prior to arrival. All arterial catheters were inserted upon patients’ arrival per CCRU clinical policy. Patients who had IABP and NIBP in the same extremity and four consecutive measurements of each modality following arterial catheter placement were eligible. Before arterial catheter placement, we recorded in real time clinicians’ decisions to manage patients’ systolic BP (SBP) according to the NIBP values and current guidelines, for example maintaining SBP ≤160 mmHg for patients with sICH. After the arterial catheter was placed, we again recorded in real time clinicians’ management of patients’ arterial SBP. We defined change in clinical management as any difference in blood pressure management (eg, adding a new antihypertensive agent, increasing or decreasing dose). We used Classification and Regression Tree (CART) analysis to identify sensitive and specific clinical predictors of management differences. A total of 183 patients were identified and analyzed, 71 (39%) female. Mean age was 63 years (standard deviation [SD] 14), mean body mass index (BMI) was 29 (6). Mean difference between IABP and NIBP and was 11 mmHg (95% CI 5-17). One hundred and seventeen patients (64%) had difference >10 mmHg between the two modalities, while 70 (38%) had a difference >20 mmHg. Seventy-nine patients (43%) had a change in management after arterial catheters were inserted. The most important factors in predicting management change included mean SBP >148 mmHg. Subsequent important factors were BMI >21, difference in BP value [IABP – NIBP] >6 mmHg, and diagnoses of ruptured abdominal aortic aneurysm, ischemic stroke + alteplase, any aortic dissection. Arterial BP monitoring identified a change in clinical management in almost half of patients with hypertensive emergencies. Clinicians should consider using arterial BP monitoring more frequently in the management of hypertensive emergencies, especially when strict BP goals are warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

CE: Hypertensive Emergencies: A Review.

While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.

Diagnosis and treatment of hypertensive disorders of pregnancy: a narrative review

The paper overviews classification, diagnosis and treatment of hypertensive disorders of pregnancy and early postpartum period (chronic hypertension (HTN), gestational HTN, pre-eclampsia) provided by different societies of cardiology and obstetrics and gynecology. The definition of pre-eclampsia offered by the International Society for the Study of Hypertension in Pregnancy (ISSHP) in 2018 and supported by the International Federation of Gynecology and Obstetrics (FIGO) in 2019, its screening and prevention are considered. All treatment options of moderate and severe HTN in pregnancy are reviewed. A new US Food and Drug Administration (FDA) classification system of drug therapy for pregnancy and lactation Pregnancy and Lactation Labelling Rule (PLLR, 2015) is presented. Treatment goals of HTN and blood pressure (BP) thresholds in pregnancy as well as risk factors, causes, clinical presentation, diagnostic workup and management of hypertensive emergencies in pregnancy are provided. We discuss the evidence of BP ≥ 130/80 mmHg as a factor of high maternal and neonatal risks proposed by the American College of Cardiology/American Heart Association (2017) as the HTN criteria in pregnancy.

Hypertension Urgencies and Emergencies: The GEAR Project.

Acute elevations in blood pressure (BP), usually defined as ≥ 180/110 mmHg, may present with highly heterogeneous profiles ranging from absence of symptoms to life-threatening target organ damage. In most recent years the diagnostic approach and the treatment of hypertension have gained interest by patients and physicians. The GEAR project (Gestione delle Emergenze e urgenze in ARea critica, management of hypertensive emergencies and hypertensive urgencies in the emergency setting) was proposed by the group of Young Investigators of the Italian Society of Hypertension as a survey aimed to evaluate the awareness, diagnosis and treatment of hypertensive emergencies and urgencies in Italy.

Blood pressure variability in the management of hypertensive emergency: A narrative review.

Hypertensive emergencies (HTNe) primarily focus on decreasing the blood pressure to specific targets. However, there are emerging data surrounding the potential clinical effects of blood pressure variability (BPV) in patients with HTNe. This narrative review highlights the various definitions of BPV, the emerging role of BPV, and the clinical data surrounding BPV in the HTNe setting. Clinical studies were obtained from a PubMed search through October 2018 utilizing PICO methodology. Original research articles, systematic reviews, and meta-analyses were considered for inclusion. Articles were selected for inclusion based on the relevancy of the article investigating BPV in the HTNe setting. There is currently no accepted standard to express BPV in the acute care setting of HTNe, and various parameters have been reported. There are very limited data regarding BPV outside of the neurologic HTNe setting. In the acute treatment phase of neurologic HTNe, BPV is consistently associated with increased risk of unfavorable outcomes. In the HTNe setting, continuous infusion of calcium channel blockers may optimize BPV compared to other agents. Based on current data, BPV should be investigated in a prospective systemic fashion. Efforts should be taken to ensure that BPV is minimized in the acute phase of HTNe, especially for those patients with intracranial hemorrhage.This reduced BPV is associated with improved favorable outcomes, but further study investigating specific pharmacologic agents is needed.

MON-429 Malady or Remedy? Hypertensive Crisis in a Young Woman with Use of St. John's Wort for Depression

Introduction St. John’s Wort (Hypericum perforatum) is a commonly available herbal supplement often used for depression and other mood disorders.1 Described below is the case of a young woman who presented with Hypertensive crisis in the setting of self-treatment of depression with St. John’s wort (SJW). Case A 39-year-old female with past history of migraines presented with blurry vision and frontal headache of 1 week duration. She was noted to have significant papilledema and blood pressure of 209/115mm hg and started on nitroprusside infusion. Physical exam was significant for relative afferent pupillary defect and also a right inferior nasal visual field cut. Work up for secondary causes of hypertension showed urine metanephrine level of 194 mcg/g/cr (32-134 mcg/g cr). Renin and aldosterone levels were not consistent with hyperaldosteronism. MRI showed Flattening of the pituitary gland and the posterior sclerae along with enlargement of the subarachnoid space around the optic nerves. Findings were suggestive of Idiopathic intracranial hypertension. Lumbar puncture showed an opening pressure of 42 cm and closing pressure of 21cm CSF. After management of hypertensive emergency in ICU, she was started on acetazolamide for intracranial hypertension and labetalol for hypertension. History of use of St John’s wort was elicited on follow up with endocrinology. Also, in the last 2 months prior to admission she could not recollect a history of excessive amounts of alcohol or cheese intake. She was asked to repeat work up after stopping SJW and labetalol being switched to amlodipine. Plasma metanephrine level repeated 2 weeks later was <25 pg/ml. Blood pressure checked 2 months after stopping SJW was noted to be 126/86 mm hg on amlodipine 10mg and Lisinopril 5mg daily. Discussion The temporal relation of SJW and hypertensive emergency and the normalization of blood pressure and plasma metanephrine levels after stopping SJW in our patient is compelling. SJW is described to act as a potent monoamine oxidase inhibitor and MAO inhibitors with excessive intake of tyramine containing foods like cheese and wine can cause hypertensive crisis. 1 The potential excess tyramine containing foods in the presence of SJW may have played a role. Also use of MAO inhibitors with other SSRI can cause Serotonin syndrome2, however our patient did not have features of serotonin syndrome. Further studies are required to elucidate the side effects of SJW and to educate the general population about such potential dangerous effects of this commonly used herbal remedy. References 1 Patel S et al. Hypertensive crisis associated with St. John’s Wort. The American Journal of Medicine, Volume 112, Issue 6, 507 - 508 2 Lawvere S. St. John’s Wort. American Family Physician. 2005 Dec 1;72(11):2249-2254.

Corrigendum to: ESC Council on hypertension position document on the management of hypertensive emergencies

Corrigendum to: ESC Council on hypertension position document on the management of hypertensive emergencies

ESC Council on hypertension position document on the management of hypertensive emergencies.

Hypertensive emergencies are those situations where very high blood pressure (BP) values are associated with acute organ damage, and therefore, require immediate, but careful, BP reduction. The type of acute organ damage is the principal determinant of: (i) the drug of choice, (ii) the target BP, and (iii) the timeframe in which BP should be lowered. Key target organs are the heart, retina, brain, kidneys, and large arteries. Patients who lack acute hypertension-mediated end organ damage do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation.

Management of hypertensive emergencies and urgencies

Management of hypertensive emergencies and urgencies

Modern management of hypertensive emergencies and urgencies: Do we need more technology, paramedics, or physicians?

Modern management of hypertensive emergencies and urgencies: Do we need more technology, paramedics, or physicians?

Trends in Hospitalization for Hypertensive Emergency, and Relationship of End-Organ Damage With In-Hospital Mortality.

There are no comprehensive guidelines on management of hypertensive emergency (HTNE) and complications. Despite advances in antihypertensive medications HTNE is accompanied with significant morbidity and mortality. We queried the 2002-2012 nationwide inpatient sample database to identify patients with HTNE. Trends in incidence of HTNE and in-hospital mortality were analyzed. Logistic regression analysis was used to assess the relationship between end-organ complications and in-hospital mortality. Between 2002 and 2012, 129,914 admissions were included. Six hundred and thirty (0.48%) patients died during their hospital stay. There was an increase in the number of HTNE admissions (9,511-15,479; Ptrend < 0.001) with concurrent reduction of in-hospital mortality (0.8-0.3%; Ptrend < 0.001) by the year 2012 compared to 2002. Patients who died during hospitalization were older, had longer length of stay, higher cost of stay, more comorbidities, and higher risk scores. Presence of acute cardiorespiratory failure [adjusted odds ratio (OR), 15.8; 95% confidence interval (CI), 13.2-18.9], stroke or transient ischemia attack (TIA) (adjusted OR, 7.9; 95% CI, 6.3-9.9), chest pain (adjusted OR, 5.9; 95% CI, 4.4-7.7), stroke/TIA (adjusted OR, 5.9; 95% CI, 4.5-7.7), and aortic dissection (adjusted OR, 5.9; 95% CI, 2.8-12.4) were most predictive of higher in-hospital mortality in addition to factors such as age, aortic dissection, acute myocardial infarction, acute renal failure, and presence of neurological symptoms. A rising trend in hospitalization for HTNE, with an overall decrease in in-hospital mortality was observed from 2002 to 2012, possibly related to changes in coding practices and improved management. Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

Diagnosis and Management of Hypertensive Emergencies Complicating Pregnancy

Diagnosis and Management of Hypertensive Emergencies Complicating Pregnancy

Hypertension The Points of Management of Hypertension for All Physicians--Based on the JSH 2014 Hypertension Guidelines--. Topics: IX. Evaluation and management of hypertensive emergencies

Hypertension The Points of Management of Hypertension for All Physicians--Based on the JSH 2014 Hypertension Guidelines--. Topics: IX. Evaluation and management of hypertensive emergencies

Hypertensive emergency and type 2 myocardial infarction resulting from pheochromocytoma and concurrent capnocytophaga canimorsus infection.

A diagnosis of myocardial infarction is made using a combination of clinical presentation, electrocardiogram and cardiac biomarkers. However, myocardial infarction can be caused by factors other than coronary artery plaque rupture and thrombosis. We describe an interesting case presenting with hypertensive emergency and type 2 myocardial infarction resulting from Pheochromocytoma associated with Capnocytophaga canimorsus infection from a dog bite. We also review current literature on the management of hypertensive emergency and Pheochromocytoma.