Hypertensive crises

Rationale for the Concept of Impending Hypertension-Mediated Organ Damage

Background:

The number of patients with hypertension urgencies (HTN-Us) and emergencies (HTN-Es) in the emergency department is relatively constant despite improved detection, awareness and control of arterial hypertension.

Objective:

This study analyses the precision of the often-used definition of HTN-E, particularly the phrase ‘with the evidence of impending or progressive hypertension-mediated organ damage (HMOD)’. We then provide a rationale for the concept of impending HMOD.

MethodS:

We searched PubMed, Science Direct, Springer, Oxford Press, Wiley, SAGE and Google Scholar and analysed the relevant definition.

Results:

The definition of HTN-E is suboptimal and requires a consensus on whether to include the phrase ‘impending hypertensive HMOD’ in the definition.

Conclusion:

A consensus on the principles of treating the ‘impending hypertensive HMOD’ does not exist, making its use inconsistent in emergency departments worldwide. In this paper, we present a rationale for the concept of ‘impending HMOD’.

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.

Characterization of patients aged 45 or under admitted with hypertensive emergencies in the Hospital do Prenda

INTRODUCTION AND OBJECTIVES

The incidence and prevalence of hypertensive emergency have been little addressed in the literature. However, over the last decade increasing numbers of young patients with different forms of hypertensive crisis have been observed in emergency departments. We performed this study to ascertain the clinical and epidemiological characteristics of patients aged ≤ 45 years admitted with a diagnosis of hypertensive emergency.

METHODS

We conducted an observational, descriptive, cross-sectional prospective study of 123 patients hospitalized for hypertensive emergency in the Hospital do Prenda, Luanda, between May 2011 and June 2012.

RESULTS

Mean age was 36.62 ± 5.49 years, and most were male (52.85%). The main risk factor was hypertension (65.9%), with 17.3% complying with therapy. The most frequent forms of presentation were hypertensive encephalopathy and hemorrhagic stroke (9.8% and 82.1%, respectively). The main drugs used were diuretics, angiotensin-converting enzyme inhibitors and calcium channel blockers. Mortality during hospitalization was 25.2% (31 patients), hemorrhagic stroke being the most common cause. There was a significant association between age and in-hospital mortality.

CONCLUSIONS

Of patients admitted with hypertensive emergency, 30.1% were aged ≤ 45 years. Hemorrhagic stroke was the most common presentation. There was a significant relationship between mode of presentation, age and in-hospital mortality.

Drug treatment of hypertensive crisis in children

Hypertensive crisis is a relatively rare event and is associated with significant morbidity and mortality in adults and pediatric patients alike. Rapid, safe, and effective treatment is imperative to alleviate immediate presenting clinical symptoms, prevent devastating morbidity, preserve long-term quality of life, and prevent mortality. Many medications in the hypertensive crisis arsenal have been used for nearly half a century. Nearly all treatment options have been utilized in children for decades, yet reliable data and sound clinical literature remain elusive. Every agent considered to be a first-line, second-line, or adjunctive option has yet to be evaluated in a randomized controlled trial in pediatric patients. With a paucity of clinical data to form evidence-based decisions, the clinician must rely entirely on the extrapolation from adult data and small retrospective studies, case series, and case reports of medication use in pediatric patients. Although more research in the treatment of pediatric hypertensive crisis is desperately needed, current practice demands a sharp knowledge of the pediatric clinical literature and pharmacology in this area as an essential tool to consistently improve patient outcomes with respect to morbidity and mortality.

Advances pertaining to the pharmacology and interactions of irreversible nonselective monoamine oxidase inhibitors

Recent advances clarifying the pharmacology and interactions of irreversible nonselective monoamine oxidase inhibitors that have not been considered in depth lately are discussed. These new data elucidate aspects of enzyme inhibition and pharmacokinetic interactions involving amine oxidases, cytochrome P450 enzymes, aminotransferases (transaminases), and decarboxylases (carboxy-lyases) and the effects of tyramine. Phenelzine and tranylcypromine remain widely available, and many publications have data relevant to this review. Their effect on CYP 450 enzymes is less than many newer drugs. Tranylcypromine only inhibits CYP 450 2A6 (selectively and potently). Phenelzine has no reported interactions, but, like isoniazid, weakly and irreversibly inhibits CYP 450 2C19 and 3A4 in vitro. It might possibly be implicated in interactions (as isoniazid is). Phenelzine has some clinically relevant inhibitory effects on amine oxidases, aminotransferases, and decarboxylases, and it lowers pyridoxal phosphate levels. It commonly causes pyridoxal deficiency, weight gain, sedation, and sexual dysfunction, but only rarely causes hepatic damage and failure, or neurotoxicity. The adverse effects and difficulties with monoamine oxidase inhibitors are less than previously believed or estimated, including a lower risk of hypertension, because the tyramine content in foods is now lower. Potent norepinephrine reuptake inhibitors have a strong protective effect against tyramine-induced hypertension. The newly discovered trace amine-associated receptors probably mediate the pressor response. The therapeutic potential of tranylcypromine and L-dopa in depression and Parkinson disease is worthy of reassessment. Monoamine oxidase inhibitors are not used to an extent proportionate with their benefits; medical texts and doctors' knowledge require a major update to reflect the evidence of recent advances.

The optometrist's role in the management of hypertensive crises

BACKGROUND

In hypertensive crises, ocular findings are pivotal to making correct management decisions. Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure (JNC-7) guidelines define hypertensive crises as blood pressure greater than 180/120 mmHg associated with signs or symptoms of target organ damage. Urgent cases are those without optic disc edema but that necessitate control within 24 to 72 hours. Emergent cases are those with optic disc edema, also known as malignant hypertension, demanding control within 1 to 6 hours.

CASE REPORTS

Two cases are illustrated, as might be seen in optometric offices, of severe stage II hypertension. In case 1, the acute elevation of blood pressure (220/110 mmHg), was assessed as an urgent case and was correctly managed with the primary care provider through outpatient care. The second case of acute elevation of blood pressure (250/150 mmHg) and ocular findings of severe hypertensive retinopathy was sent as an emergent case to the emergency room.

CONCLUSION

These cases exemplify optometric in-office decisions to effectively manage urgent and emergent cases of hypertensive crises. Utilizing an urgent versus emergent classification of retinopathy can lead to the appropriate management decision for these patients.

Drug abuse in plastic surgery patients: optimizing detection and minimizing complications

Drugs of abuse present numerous challenges to plastic surgeons, and detection remains difficult. With rates of drug abuse and misuse on the rise, clinicians must remain especially attentive to drug abusers' verbal and nonverbal cues, and be familiar with treating perioperative complications if they arise. Informed deductions regarding drug abuse can enable a plastic surgeon to identify drug abuse, minimize complications, and optimize patient care.