Intravenous clevidipine for management of hypertension

The Current Role of Clevidipine in the Management of Hypertension

Acute hypertension, which may damage blood vessels, causes irreversible organ damage to the vasculature, central nervous system, kidney, and heart. Clevidipine, the first third-generation calcium channel antagonist approved by the Food and Drug Administration (FDA) in the past 20 years, is an ultra-short-acting calcium channel blocker that inhibits L-type calcium channels with high clearance and low distribution, can be rapidly metabolized into the corresponding inactive acid, and is rapidly hydrolyzed into inactive metabolites by esterase in arterial blood. Clevidipine is the same as nicardipine in that the main physiological effect is vasodilation and the main target is the arterial system, which has a limited effect on capacitor vessels. Unlike nitroglycerin, clevidipine has a limited effect on preload. In contrast to other direct-acting vasodilators, clevidipine has an ultra-short half-life due to metabolism by nonspecific blood and tissue esterases. Clevidipine trials conducted in adult populations have proven that it can rapidly control blood pressure in cardiac surgery situations and that adverse reactions to clevidipine are similar to those with other antihypertensive agents. In recent years, clinical trials have shown that clevidipine has excellent blood pressure-lowering capability in patients with acute neurological injury (hemorrhage, stroke, and subarachnoid and acute intracerebral hemorrhage), those  undergoing coronary artery bypass graft or spinal surgery, and in those with cerebral aneurysm/pheochromocytoma, acute heart failure, acute aortic syndromes, or renal insufficiency with severe hypertension, and it is equivalent to commonly used blood pressure-lowering medicines such as nicardipine or nitroglycerin. However, there is a lack of large-scale clinical trial data on the efficacy and safety of clevidipine in children during the perioperative period.

Scleroderma renal crisis: a review for emergency physicians

Scleroderma renal crisis (SRC) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of SRC. While SRC remains a rare clinical presentation, surveillance data suggest an overall incidence between 4 and 6% of patients with scleroderma. The diagnostic criteria for SRC include a new onset blood pressure > 150/85 mm Hg OR increase ≥ 20 mm Hg from baseline systolic blood pressure, along with a decline in renal function, defined as an increase serum creatinine of ≥ 10% and supportive features. There are many risk factors for SRC, including diffuse and rapidly progressive skin thickening, palpable tendon friction rubs, and new anemia or cardiac events. Critical patients should be evaluated in the resuscitation bay, and consultation with the nephrology team for appropriate patients improves patient outcomes.

Advances in management of acute hypertension: a concise review

Chronic hypertension affects >1 billion people worldwide and >70 million people in the United States. Acute hypertensive episodes (AHE) are defined as severe spikes in blood pressure that may result in end-organ damage. Although AHE may arise independently as de novo events, they are more likely to occur in patients with pre-existing hypertension. One of the controversies regarding the clinical approach to AHE is the selection of anti-hypertensive medication. Depending on the clinical presentation of the patient and the threat of end-organ damage resulting from blood pressure elevation, appropriate and prompt treatment is warranted. There are multiple agents available for the management of hypertension. However, the greatest challenge lies in the acute care setting where the need exists for better initial and sustained control of blood pressure spikes. Many anti-hypertensive agents effectively lower blood pressure, yet only few have the capacity to achieve strict control of hypertension in the acute setting. Clevidipine butyrate is an ultra short-acting intravenous dihydropyridine calcium-channel blocker. Clevidipine has unique pharmacodynamic and pharmacokinetic properties that enable the fast, safe, and adequate reduction of blood pressure in hypertensive emergencies, with the ability to provide highly precise titration necessary to maintain a narrowly-defined target blood pressure range. Several recently published phase I, II, and III clinical studies have shown Clevidipine to be an effective blood pressure modulator in such capacity.