TREATMENT OF PERIOPERATIVE HYPERTENSION

Perioperative hypertension: defining at-risk patients and their management

Hypertension is an extremely pervasive condition that affects a large percentage of the world population. Although guidelines exist for the treatment of the patient with elevated blood pressure, there remains a paucity of literature and accepted guidelines for the perioperative evaluation and care of the patient with hypertension who undergoes either cardiac or noncardiac surgery. Of particular importance is defining the patients most vulnerable to complications and the indications for immediate and rapid antihypertensive treatment and/or cancellation of surgery to reduce these risks in each of the three perioperative settings: preoperative, intraoperative, and postoperative. This review also examines the parenteral antihypertensive medications most commonly administered in the perioperative setting.

Clevidipine butyrate: a promising new drug for the management of acute hypertension

Clevidipine butyrate is an ultrashort-acting intravenous dihydropyridine calcium-channel blocker that has been approved by the FDA for the reduction of blood pressure when oral therapy is not feasible. Hypertension is a global disease that affects more than 1 billion people worldwide and 75 million people in the USA. There are multiple agents available for the management of hypertension. The acute setting is where the challenge arises for developing new agents that not only decrease, but more importantly, optimally control blood pressure. Many drugs lower blood pressure; however, only a few have the capacity to precisely control hypertension in the acute phase. Clevidipine has unique pharmacodynamic and pharmacokinetic properties that enable the fast, safe and adequate reduction of blood pressure in hypertensive emergencies, with unique precision necessary to maintain the target blood pressure range. Its use in different clinical settings has been evaluated in several Phase I, II and III clinical studies. It is easily administered and titrated with minimal side effects, achieves fast control with low doses, is highly successful as monotherapy and allows excellent transition to oral medication. Thus, clevidipine is a promising new agent for the management of acute hypertension in a variety of clinical settings.

Strategies for managing perioperative hypertension

Acute perioperative hypertension is associated with a higher risk of perioperative myocardial ischemia, bleeding, stroke, and renal failure. The immediate concern of short-term antihypertensive therapy is to prevent excessive surgical bleeding from arterial anastomoses, myocardial ischemia, and neurologic complications while causing minimal adverse effects until oral therapy can be resumed. This article reviews perioperative hypertension emergencies/urgencies and various approaches for management.

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.

Diagnosis and management of labile blood pressure during acute cerebrovascular accidents and other hypertensive crises

It is estimated that with more than 40 million adults in the United States having uncontrolled hypertension, the risk of developing ischemic or hemorrhagic stroke in this population is significant. In addition, roughly 1 of 100 patients with essential hypertension will experience a hypertensive crisis during their lifetime, and these accelerated hypertensive emergencies and urgencies complicate more than 27% of all acute medical problems in patients presenting to emergency departments (EDs) in the United States. Arterial hypertension, a prominent feature of acute stroke syndrome, usually declines spontaneously within a few days, but its presence at hospital admission or its acute development during hospitalization is often associated with worsening stroke outcome and early mortality. Control of hypertension in patients with subarachnoid and intracerebral hemorrhage, both forms of acute stroke, is directed at maintaining adequate cerebral blood flow to minimize ischemic damage and control intracerebral pressure while reducing the risk of rebleeding and developing cerebrovasospasm. Inappropriate lowering of the blood pressure in acute stroke may increase neurologic damage. However, adequate blood flow around the central area of the acute ischemic stroke or penumbra may result in ischemic cells being salvaged. Clinicians must be mindful that accelerated hypertension is associated with other types of patients seen in the ED, such as perioperative patients and patients with traumatic head injuries.

Hypertensive crises: challenges and management

Hypertension affects > 65 million people in the United States and is one of the leading causes of death. One to two percent of patients with hypertension have acute elevations of BP that require urgent medical treatment. Depending on the degree of BP elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. A hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting IV antihypertensive agent. Severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents. This article reviews definitions, current concepts, common misconceptions, and pitfalls in the diagnosis and management of patients with acutely elevated BP as well as special clinical situations in which BP must be controlled.