Parenteral hydralazine revisited

Retrospective analysis of risk factors of hypotensive bradycardic events during shoulder arthroscopic surgery under interscalene blockade in the sitting position

Background

Hypotensive bradycardic events (HBEs) are a frequent adverse event in patients who underwent shoulder arthroscopic surgery under interscalene block (ISB) in the sitting position. This retrospective study was conducted to investigate the independent risk factors of HBEs in shoulder arthroscopic surgery under ISB in the sitting position.

Methods

A total of 2549 patients who underwent shoulder arthroscopic surgery under ISB and had complete clinical data were included in the study. The 357 patients who developed HBEs were included in the HBEs group, and the remaining 2192 in the non-HBEs group. The potential risk factors for HBEs, such as age, sex, past medical history, anesthetic characteristics, and intraoperative medications were collected and compared between the groups. Statistically significant variables were included in a logistic regression model to further evaluate the independent risk factors for HBEs in shoulder arthroscopic surgery under ISB.

Results

The incidence of HBEs was 14.0% (357/2549). Logistic regression analysis revealed that the intraoperative use of hydralazine (odds ratio [OR] 4.2; 95% confidence interval [CI] 2.9–6.3), propofol (OR 2.1; 95% CI 1.3–3.6), and dexmedetomidine (OR 3.9; 95% CI 1.9–7.8) before HBEs were independent risk factors for HBEs in patients who received shoulder arthroscopic surgery under ISB.

Conclusions

The intraoperative use of antihypertensives such as hydralazine and sedatives such as propofol or dexmedetomidine leads to increased risk of HBEs during shoulder arthroscopic surgery under ISB in the sitting position.

Management of hypertensive crises in the elderly

Hypertensive crises are elevations of blood pressure higher than 180/120 mmHg. These can be urgent or emergent, depending on the presence of end organ damage. The clinical presentation of hypertensive crises is quite variable in elderly patients, and clinicians must be suspicious of non-specific symptoms. Managing hypertensive crises in elderly patients needs meticulous knowledge of the pathophysiological changes in them, pharmacological options, pharmacokinetics of the medications used, their side effects, and their interactions with other medications. Clevidipine, nicardipine, labetalol, esmolol, and fenoldopam are among the preferred choices in the elderly due to their efficacy and tolerability. Nitroprusside, hydralazine, and nifedipine should be avoided, unless there are no other options available, due to the high risk of complications and unpredictable responses.

Direct Vasodilators and Sympatholytic Agents

Direct vasodilators and sympatholytic agents were some of the first antihypertensive medications discovered and utilized in the past century. However, side effect profiles and the advent of newer antihypertensive drug classes have reduced the use of these agents in recent decades. Outcome data and large randomized trials supporting the efficacy of these medications are limited; however, in general the blood pressure-lowering effect of these agents has repeatedly been shown to be comparable to other more contemporary drug classes. Nevertheless, a landmark hypertension trial found a negative outcome with a doxazosin-based regimen compared to a chlorthalidone-based regimen, leading to the removal of α-1 adrenergic receptor blockers as first-line monotherapy from the hypertension guidelines. In contemporary practice, direct vasodilators and sympatholytic agents, particularly hydralazine and clonidine, are often utilized in refractory hypertension. Hydralazine and minoxidil may also be useful alternatives for patients with renal dysfunction, and both hydralazine and methyldopa are considered first line for the treatment of hypertension in pregnancy. Hydralazine has also found widespread use for the treatment of systolic heart failure in combination with isosorbide dinitrate (ISDN). The data to support use of this combination in African Americans with heart failure are particularly robust. Hydralazine with ISDN may also serve as an alternative for patients with an intolerance to angiotensin antagonists. Given these niche indications, vasodilators and sympatholytics are still useful in clinical practice; therefore, it is prudent to understand the existing data regarding efficacy and the safe use of these medications.

Control of hypertension in the critically ill: a pathophysiological approach

Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options.

Perioperative hypertension: a review of current and emerging therapeutic agents

Perioperative hypertension is a common problem encountered by anesthesiologists, surgeons, internists, and intensivists. Surprisingly, no randomized, placebo-controlled studies exist that show that the treatment of perioperative hypertension reduces morbidity or mortality. Nevertheless, perioperative hypertension requires careful management. While sodium nitroprusside and nitroglycerin are commonly used to treat these conditions, these agents are less than ideal. Intravenous beta blockers and calcium channel blockers have particular appeal in this setting.

4-Hydrazino-2-(methylsulfanyl)pyrimidine

In the crystal of the title compound, C₅H₈N₄, centrosymmetric dimers are linked by pairs of N—H⋯N hydrogen bonds. Further N—H⋯N links result in a two-dimensional array whereby wave-like supra­molecular chains are inter­connected by R₂²(8) ring motifs.

Potentialities and pitfalls accompanying chemico-pharmacological strategies against endogenous electrophiles and carbonyl stress

The use of powerful analytical technologies to detect endogenous carbonyls formed as byproducts of oxidative cell injury has revealed that these species contribute to many human diseases. As electrophiles, they are attacked by reactive centers in cell macromolecules to form adducts, the levels of which serve as useful biomarkers of oxidative cell injury. Because the pathobiological significance of such damage is often unclear, the possibility of using low molecular weight drugs as exploratory sacrificial nucleophiles to intercept reactive carbonyls within cells and tissues is appealing. This perspective highlights the potential benefits of using carbonyl scavengers to evaluate the significance of endogenous carbonyls in particular diseases but also canvasses a number of challenges confronting this therapeutic strategy. Chief among the latter is the task of confirming that carbonyl sequestration underlies any suppression of disease symptoms elicited by these multipotent reagents, an issue needing clarification if these compounds are to command consideration as drug interventions in humans. Other problems include adverse consequences of reactions between carbonyl scavengers and important endogenous carbonyls (e.g., neurotoxicity due to pyridoxal depletion), as well as the potential for drugs to form ternary complexes with carbonylated cell proteins, raising the prospect of immunotoxicological outcomes. Strategies for moving carbonyl sequestering reagents from the laboratory bench to a clinical testing environment are discussed within the context of the search for new treatments for spinal cord injury, one of the most debilitating medical conditions sustainable by humans. This condition seems an appropriate test case for assessing carbonyl sequestering drugs given growing evidence for noxious carbonyls in the wave of neuronal cell death that follows traumatic injury to the spinal cord.

Perioperative hypertension management

Perioperative hypertension is commonly encountered in patients that undergo surgery. While attempts have been made to standardize the method to characterize the intraoperative hemodynamics, these methods still vary widely. In addition, there is a lack of consensus concerning treatment thresholds and appropriate therapeutic targets, making absolute recommendations about treatment difficult. Nevertheless, perioperative hypertension requires careful management. When treatment is necessary, therapy should be individualized for the patient. This paper reviews the pharmacologic agents and strategies commonly used in the management of perioperative hypertension.

Hydralazine target: from blood vessels to the epigenome

Hydralazine was one of the first orally active antihypertensive drugs developed. Currently, it is used principally to treat pregnancy-associated hypertension. Hydralazine causes two types of side effects. The first type is an extension of the pharmacologic effect of the drug and includes headache, nausea, flushing, hypotension, palpitation, tachycardia, dizziness, and salt retention. The second type of side effects is caused by immunologic reactions, of which the drug-induced lupus-like syndrome is the most common, and provides clues to underscoring hydralazine's DNA demethylating property in connection with studies demonstrating the participation of DNA methylation disorders in immune diseases. Abnormalities in DNA methylation have long been associated with cancer. Despite the fact that malignant tumors show global DNA hypomethylation, regional hypermethylation as a means to silence tumor suppressor gene expression has attracted the greatest attention. Reversibility of methylation-induced gene silencing by pharmacologic means, which in turns leads to antitumor effects in experimental and clinical scenarios, has directed efforts toward developing clinically useful demethylating agents. Among these, the most widely used comprise the nucleosides 5-azacytidine and 2'deoxy-5-azacytidine; however, these agents, like current cytotoxic chemotherapy, causes myelosuppression among other side effects that could limit exploitation of their demethylating properties. Among non-nucleoside DNA demethylating drugs currently under development, the oral drug hydralazine possess the ability to reactivate tumor suppressor gene expression, which is silenced by promoter hypermethylation in vitro and in vivo. Decades of extensive hydralazine use for hypertensive disorders that demonstrated hydralazine's clinical safety and tolerability supported its testing in a phase I trial in patients with cancer, confirming its DNA demethylating activity. Hydralazine is currently being evaluated, along with histone deacetylase inhibitors either alone or as adjuncts to chemotherapy and radiation, for hematologic and solid tumors in phase II studies.

Antioxidant activity and inhibitory effects of hydralazine on inducible NOS/COX-2 gene and protein expression in rat peritoneal macrophages

This study investigated the effects of the peripheral vasodilator hydralazine on in vitro generation of reactive species of oxygen (ROS), nitrogen (RNS) and prostaglandin (PG) biosynthesis in elicited murine peritoneal macrophages, and on the gene expression and protein synthesis of two key enzymes in the inflammatory process, inducible NO(*) synthase (NOS-2) and inducible cyclooxygenase 2 (COX-2). Hydralazine at 0.1-10 mM inhibited both extracellular and intracellular ROS production by inflammatory macrophages, by a ROS-scavenging mechanism probably affecting superoxide radical (O(2)(*-))-generation by xanthine oxidase (XO) and nicotinamide adenine dinucleotide/nicotinamide adenine dinucleotide phosphate (NADH/NADPH) oxidase. Hydralazine at 0.1-10 mM significantly reduced NO(*) generation, and this effect was attributable to an inhibition of NOS-2 gene expression and protein synthesis. At 1-10 mM, hydralazine also effectively blocked COX-2 gene expression which perfectly correlated with a reduction of protein levels and PGE(2) synthesis. These data suggest that hydralazine, at the concentrations tested, show antioxidant properties and strongly attenuates the macrophage activation.

Effects of hydrazine derivatives on vascular smooth muscle contractility, blood pressure and cGMP production in rats: comparison with hydralazine

Hydralazine is a hydrazine derivative used clinically as a vasodilator and antihypertensive agent. Despite numerous studies with the drug, its mechanism of action has remained unknown; guanylate cyclase activation and release of endothelial relaxing factors are thought to be involved in its vasodilator effect. Other hydrazine derivatives are known to stimulate guanylate cyclase and could therefore share the vasodilator activity of hydralazine, although such possibility has not been assessed systematically. In the present study, hydralazine, hydrazine, phenylhydrazine, and isoniazid were evaluated for vascular smooth muscle relaxation in rat aortic rings with and without endothelium, as well as after incubation with the guanylate cyclase inhibitor methylene blue. They were also tested for enhancement of cyclic guanosine monophosphate (cGMP) production by cultured rat aortic smooth muscle cells and for hypotension in the anesthetized rat. All hydrazines relaxed aortic rings, an action unaffected by endothelium removal and, in all cases except hydralazine, antagonized by methylene blue. Only phenylhydrazine increased cGMP production and only hydralazine markedly lowered blood pressure. It was concluded that hydralazine vascular relaxation is independent of endothelium and is not related to guanylate cyclase activation. The other hydrazines studied also elicit endothelium-independent relaxation, but the effect is related to guanylate cyclase. The marked hypotensive effect of hydralazine contrasts with its modest relaxant activity and is not shared by the other hydrazines. The fact that hydrazine and isoniazid produce methylene blue-sensitive relaxation, yet do not enhance cGMP production suggests the need for activating factors present in aortic rings but not in isolated cells.

Hypertensive emergencies

In summary, patients presenting with a true hypertensive emergency should be diagnosed quickly and promptly started on effective parenteral therapy (typically nitroprusside 0.5 microgram/kg/min or fenoldopam 0.1 microgram/kg/min) in an intensive care unit. Blood pressure should be reduced about 25% gradually over 2 to 3 hours. Oral antihypertensive therapy (often with an immediate-release calcium antagonist) can be instituted after 6 to 12 hours of parenteral therapy, and consideration should be given to secondary causes of hypertension after transfer out of the intensive care unit. Because of advances in antihypertensive therapy and management, "malignant hypertension" should be truly malignant no longer.

Enhancement of hydralazine hypotension by low doses of isoniazid. Possible role of semicarbazide-sensitive amine oxidase inhibition

The influence of pretreatment with 1 through 300 mg/kg ip of isoniazid (ISO) on blood pressure and heart rate responses to 0.1 mg/kg iv of hydralazine (HYD) was assessed in rats anesthetized with chloralose--urethane. HYD hypotension was significantly enhanced by ISO at doses between 3 and 300 mg/kg ip. Heart rate was not influenced by HYD in control or pretreated animals. Depressor responses to 0.2 mg/kg iv of pinacidil (PIN) were also potentiated by ISO at 100 and 300, but not at 30 mg/kg. Similarly, ISO decreased cerebral gamma-aminobutyric acid (GABA) at the two highest doses; 30 mg/kg was without effect. Pretreatment of rats with ISO at 1 through 300 mg/kg failed to influence HYD-induced relaxation of aortic rings. These results were interpreted as indicating that potentiation of HYD hypotension by high doses of ISO is not specific for that vasodilator and is related to decreased cerebral GABA, as postulated previously. Lower doses could specifically potentiate the HYD-induced hypotensive effect by inhibition of semicarbazide-sensitive amine oxidase (SSAO), since both ISO and HYD are potent inhibitors of this enzyme. In support of this hypothesis, the SSAO inhibitors, benserazide (100 mg/kg ip) and mexiletine (50 mg/kg ip), were also found to enhance HYD hypotension.

Treatment of hypertension in the perioperative patient

OBJECTIVE

To review studies and drug therapy relating to the treatment of hypertension in perioperative patients.

DATA SOURCES

Articles were selected from a MEDLINE search (1966-August 1998), and several textbooks on hypertension and surgery were reviewed. In addition, bibliographies of all articles and textbook chapters were studied for articles not found in the computerized searches.

STUDY SELECTION

Clinical studies involving hypertension in the perioperative setting were included. The initial search was limited to studies conducted in humans and published in English.

DATA EXTRACTION

Information regarding drug therapy was reviewed and guidelines were constructed for managing surgical patients with acute blood pressure elevations.

DATA SYNTHESIS

Although nitroprusside and nitroglycerin, with their short onset of action and duration of effect, are indicated for hypertensive emergencies, a variety of agents are available for hypertensive urgencies. An algorithm that can be used as a template for the development of intrainstitutional guidelines is provided.

CONCLUSIONS

Due to the scarcity of comparative trials, decisions involving agents for the treatment of perioperative hypertension must often be made based on combined efficacy, toxicity, cost, and convenience considerations.

Anesthetic management of preeclampsia/eclampsia

Preeclampsia/eclampsia affects only a small proportion of all pregnancies, yet accounts for much of the obstetric morbidity and mortality seen in the USA and UK. A full understanding of preeclampsia/eclampsia, its variable presentation and complex pathophysiology allows the consulting anesthesiologist to optimize a plan for anesthetic management of the afflicted patient.