Comparative tolerability profile of hypertensive crisis treatments

Nitroprusside and metal nitroprusside nano analogues for cancer therapy

Sodium nitroprusside (SNP), U.S approved drug has been used in clinical emergency as a hypertensive drug for more than a decade. It is well established for its various biomedical applications such as angiogenesis, wound healing, neurological disorders including anti-microbial applications etc. Apart from that, SNP have been considered as excellent biomedical materials for its use as anti-cancer agent because of its behavior as NO-donor. Recent reports suggest that incorporation of metals in SNP/encapsulation of SNP in metal nanoparticles (metal nitroprusside analogues) shows better therapeutic anti-cancer activity. Although there are numerous reports available regarding the biological applications of SNP and metal-based SNP analogue nanoparticles, unfortunately there is not a single comprehensive review which highlights the anti-cancer activity of SNP and its derivative metal analogues in detail along with the future perspective. To this end, the present review article focuses the recent development of anti-cancer activity of SNP and metal-based SNP analogues, their plausible mechanism of action, current status. Furthermore, the future perspectives and challenges of these biomedical materials are also discussed. Overall, this review article represents a new perspective in the area of cancer nanomedicine that will attract a wider spectrum of scientific community.

Impact of early initiation of renin-angiotensin blockade on renal function and clinical outcomes in patients with hypertensive emergency: a retrospective cohort study

BACKGROUND

Hypertensive emergency is a critical disease that causes multifaceted sequelae, including end-stage kidney disease and cardiovascular disease. Although the renin-angiotensin-aldosterone (RAA) system is enormously activated in this disease, there are few reports that attempt to characterize the effect of early use of RAA inhibitors (RASi) on the temporal course of kidney function.

METHODS

This retrospective cohort study was conducted to clarify whether the early use of RASi during hospitalization offered more favorable benefits on short-term renal function and long-term renal outcomes in patients with hypertensive emergencies. We enrolled a total of 49 patients who visited our medical center with acute severe hypertension and multiple organ dysfunction between April 2012 and August 2020. Upon admission, the patients were treated with intravenous followed by oral antihypertensive drugs, including RASi and Ca channel blockers (CCB). Kidney function as well as other laboratory and clinical parameters were compared between RASi-treated and CCB- treated group over 2 years.

RESULTS

Antihypertensive treatment effectively reduced blood pressure from 222 ± 28/142 ± 21 to 141 ± 18/87 ± 14 mmHg at 2 weeks and eGFR was gradually restored from 33.2 ± 23.3 to 40.4 ± 22.5 mL/min/1.73m² at 1 year. The renal effect of antihypertensive drugs was particularly conspicuous when RASi was started in combination with other conventional antihypertensive drugs at the early period of hospitalization (2nd day [IQR: 1-5.5]) and even in patients with moderately to severely diminished eGFR (< 30 mL/min/1.73 m²) on admission. In contrast, CCB modestly restored eGFR during the observation period. Furthermore, renal survival probabilities were progressively deteriorated in patients who had manifested reduced eGFR (< 15 mL/min/1.73 m²) or massive proteinuria (urine protein/creatinine ≥ 3.5 g/gCr) on admission. Early use of RASi was associated with a favorable 2-year renal survival probability (0.90 [95%CI: 0.77-1.0] vs. 0.63 [95%CI: 0.34-0.92] for RASi ( +) and RASi (-), respectively, p = 0.036) whereas no apparent difference in renal survival was noted for CCB.

CONCLUSIONS

Early use of RASi contributes to the renal functional recovery from acute reduction in eGFR among patients with hypertensive emergencies. Furthermore, RASi offers more favorable effect on 2-year renal survival, compared with CCB.

Diazoxide-Induced Hypertrichosis in a Neonate With Transient Hyperinsulinism

Diazoxide is one of the FDA-approved pharmacologic treatments for hyperinsulinemic hypoglycemia, however, its adverse effects in infants are not well described. We reported a 37-week-old boy with the diagnosis of hypoglycemia. We started a dextrose infusion, but we used oral diazoxide, due to hypoglycemia episodes despite the increase in dextrose intake. The newborn had a normoglycemic condition after gradually increasing the diazoxide dose to 15 mg/kg/day. He was fully breastfed and discharged at 14 days of age with ongoing diazoxide. In weekly serial clinical follow-ups, the parents noticed an increase in the growth of forehead and facial hair that was diagnosed as diazoxide-induced hypertrichosis. Diazoxide was gradually tapered, and hypertrichosis continued until 1 month after dioxide discontinuation. Diazoxide use in NICU settings has increased over time. Diazoxide has many side effects, one of which is hypertrichosis. Many diazoxide side effects have been reported in adults or children and few studies have reported the prevalence of these adverse effects of diazoxide in neonates and infants.

Oral agents for acute severe hypertension in children with minimal or no symptoms

Acute hypertension is common among children admitted to hospital, and large or rapid increases in blood pressure place children at risk of complications such as posterior reversible encephalopathy syndrome. Guidelines in the United States and Europe now include definitions guiding the identification of acute severe hypertension (otherwise known as hypertensive crisis) and its management. This review discusses these recommendations and the appropriate use of oral antihypertensive agents for children with minimal or no symptoms. We focus on the role of oral calcium channel blockers, including isradipine (a second-generation dihydropyridine), given recent changes to regulatory approvals in Australia. The differing pharmacokinetic and pharmacodynamic properties of agents are compared, with the aim of facilitating directed drug selection and dosing.

Amphetamine and Clonidine Toxicity Resulting in Posterior Reversible Encephalopathy Syndrome

ABSTRACT

Amphetamine toxicity typically presents with hypertension and tachycardia. Conversely, clonidine acts as an agonist at central α2 and imidazoline receptors, which may cause brief initial hypertension followed by hypotension and bradycardia in overdose. We report a case of mixed ingestion resulting in posterior reversible encephalopathy syndrome (PRES) successfully treated with phentolamine.A 17-year-old male adolescent presented to the emergency department 2 hours after ingesting up to 25 each of clonidine 0.1-mg tablets and dextroamphetamine 10 mg extended-release capsules. He reported nausea and fatigue with initial blood pressure (BP) 145/95 mm Hg and heart rate (HR) 52 beats per minute (bpm). Nine hours postingestion (HPI), the patient developed headache, photophobia, and confusion with BP 182/111 mm Hg and HR 48 bpm. A computed tomography scan of the head revealed generalized fullness of the cerebellum, upward bulging of the tentorial leaflets, effacement of the fourth ventricle, and crowding of the foramen magnum, suspicious for an atypical presentation of PRES. The patient's systolic BP rose over 200 mm Hg and treated with 2 mg of intravenous phentolamine at 14 HPI. Blood pressure decreased to 133/82 mm Hg, and HR increased to 56 bpm with improvements in headache. Following repeat doses of phentolamine, nicardipine was initiated and increased to 2.5 mg/h for 12 hours. The patient was stable with normal vital signs at 36 HPI.The delayed presentation of hypertensive emergency with PRES may have been due to the actions of extended-release dextroamphetamine and the α2-agonistic effects of clonidine. Phentolamine was chosen for its α1-antagonism and was effective in managing symptoms.

Hypertensive Crisis in Pediatric Patients: An Overview

Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.

Association of normal systolic blood pressure in the emergency department with higher in-hospital mortality among hypertensive patients

Blood pressure is commonly elevated at the hospital emergency department (ED), especially among hypertensive patients. The aim of the study was to determine the association between ED systolic blood pressure (SBP) and in-hospital mortality among hypertensive patients. The authors retrospectively retrieved records of hypertensive patients who were hospitalized during a seven-year period. The authors examined the association between SBP and in-hospital mortality rate, adjusted for demographics, heart rate, comorbidities, laboratory results, and hospital ward. Overall, 96 423 patients were included. Compared to patients with SBP 110-139 mm Hg, the adjusted odds ratios were 4.1 (95% CI, 3.7-4.6) with SBP <90, 1.6 (95% CI, 1.4-1.7) with SBP 90-109, 0.7 (95% CI, 0.6-0.7) with SBP 140-159, 0.7 (95% CI, 0.6-0.7) with SBP 160-179, 0.7 (95% CI, 0.6-0.8) with SBP 180-199, 0.9 (95% CI, 0.7-1.1) with SBP 200-219, and 1.1 (95% CI, 0.7-1.7) with SBP ≥220 mm Hg. Thus, SBP levels of 110-139 mm Hg were associated with higher in-hospital mortality in comparison with elevated SBP up to 200 mm Hg.

Acute Management of Hypertension Following Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is responsible for approximately 15% of strokes annually in the United States, with nearly 1 in 3 of these patients dying without ever leaving the hospital. Because this disproportionate mortality risk has been stagnant for nearly 3 decades, a main area of research has been focused on the optimal strategies to reduce mortality and improve functional outcomes. The acute hypertensive response following ICH has been shown to facilitate ICH expansion and is a strong predictor of mortality. Rapidly reducing blood pressure was once thought to induce cerebral ischemia, though has been found to be safe in certain patient populations. Clinicians must work quickly to determine whether specific patient populations may benefit from acute lowering of systolic blood pressure (SBP) following ICH. This review provides nurses with a summary of the available literature on blood pressure control following ICH. It focuses on intravenous and oral antihypertensive medications available in the United States that may be utilized to acutely lower SBP, as well as medications outside of the antihypertensive class used during the acute setting that may reduce SBP.

Acute Kidney Injury, Recurrent Seizures, and Thrombocytopenia in a Young Patient with Lupus Nephritis: A Diagnostic Dilemma

Introduction. Posterior reversible encephalopathy syndrome (PRES) is a constellation of clinical and radiologic findings. Fluctuations in blood pressure, seizures, and reversible brain MRI findings mainly in posterior cerebral white matter are the main manifestations. PRES has been associated with multiple conditions such as autoimmune disorders, pregnancy, organ transplant, and thrombotic microangiopathy (TMA). Case Presentation. A 22-year-old woman with history of Systemic Lupus Erythematous complicated with chronic kidney disease secondary to lupus nephritis class IV presented with recurrent seizures and uncontrolled hypertension. She was found to have acute kidney injury and thrombocytopenia. Repeat kidney biopsy showed diffuse endocapillary and extracapillary proliferative and membranous lupus nephritis (ISN-RPS class IV-G+V) and endothelial swelling secondary to severe hypertension but no evidence of TMA. Brain MRI showed reversible left frontal and parietal lesions that resolved after controlling the blood pressure, making PRES the diagnosis. Conclusion. PRES is an important entity that must be recognized and treated early due to the potential reversibility in the early stages. Physicians must have high suspicion for these unusual presentations. We present a case where performing kidney biopsy clinched the diagnosis in our patient with multiple confounding factors.

An Emergency Department Approach to Drug Treatment of Hypertensive Urgency and Emergency

Patients who present with hypertensive urgency or emergency require immediate attention to assess the severity of illness. Guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure are available but do little to address the management of acute elevations in blood pressure. Various treatment options, both old and new, exist to manage these patients in the emergency department. Decisions on therapy are patient specific and depend on the underlying cause of elevated blood pressure. This article sets out to describe specific patient presentations and reviews current available options in the management of hypertensive urgencies and emergencies.

Therapy of acute hypertension in hospitalized children and adolescents

Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.

COMBINED ACTION ANTIHYPERTENSIVE AGENT URAPIDIL: EFFECTIVENESS AND SAFETY IN CLINICAL PRACTICE

The paper reviews the clinical practice potential of a combined action antihypertensive medication urapidil for the treatment of patients with acute elevation of blood pressure (BP) and confirms urapidil effectiveness and good tolerability. Urapidil action mechanisms, pharmacodynamics, and pharmacokinetics are discussed, together with the results of the key clinical trials which have demonstrated antihypertensive effectiveness and safety of this agent. Additional beneficial effects of urapidil, such as reduction of the increased pulmonary artery BP and improvement of bronchial conductivity, are also described.

ANTIHYPERTENSIVE THERAPY TACTICS IN HYPERTENSIVE CRISE COMPLICATED BY HAEMORRHAGIC STROKE

Aim. To identify the optimal tactics of antihypertensive therapy (AHT) in patients with hypertensive crise (HC), complicated by haemorrhagic stroke (HS).

Material and methods. Forty patients aged 46–87 years, who were hospitalised with HC and HS as its complication.

Results. All patients were divided into two groups, according to the median levels of systolic blood pressure (SBP) at 20 minutes after the start of the treatment: SBP >161 mm Hg vs. SBP <161 mm Hg. A significantly better survival was observed in patients with a higher degree of the 20-minute SBP eduction. In addition, patients were divided into tertiles of the 20-minute SBP levels. Participants with SBP 136–149 mm Hg demonstrated a significantly better survival. The degree of SBP reduction at 220 minutes was not significantly associated with survival. Furthermore, the patients were divided into two groups by the rate of SBP reduction. Faster rates were associated with a better survival (PGW=0,002). The second part of the study was focused on the assessment of effectiveness and safety of urapidil hydrochloride (Ebrantil). The patients were randomised into two groups: one group was administered Ebrantil, while another received the standard neuroresuscitation unit treatment. Ebrantil therapy demonstrated a fast and effective SBP reduction at 20 minutes, which was also associated with a better survival.

Conclusion. We identified optimal, associated with a better survival, BP levels (136–149 mm Hg) for patients with HC complicated by HS. Target BP levels should be achieved within 20 minutes, as a slower BP reduction is linked to a worse prognosis. Ebrantil is an effective and safe antihypertensive medication.

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.

Blood Pressure Monitoring in the Assessment of Old Patients with Acute Stroke

Background

Most patients have elevated blood pressure in the early phase of acute stroke that it often returns to normal within approximately seven-days. Most available data on the pattern of blood pressure in acute stroke are based on manual blood pressure measurements.

Aims

The aims of the present study were to assess with 24 h blood pressure monitoring the pattern of blood pressure in acute stroke, and the change in blood pressure during the first week of event in very old patients.

Methods

We studied 99 patients with acute stroke (58 males), mean age 83 ± 6 years (range 70–97). Casual blood pressure and 24 h blood pressure monitoring were recorded within 24 h of admission, and then after six- to seven-days.

Results

Casual blood pressure before beginning the 24 h blood pressure monitoring was 154 ± 23/80 ± 15 mmHg and the average 24 h blood pressure was 147 ± 20/74 ± 11 mmHg. One-week after stroke, casual blood pressure decreased by 15/7 mmHg, whereas 24 h blood pressure decreased by only 7/2 mmHg ( P<0·01). Blood pressure decreased remarkably only in those with admission elevated systolic blood pressure. The change in 24 h systolic blood pressure after one-week correlated to the 24 h admission systolic blood pressure ( R=0·47; P<0·01).

Conclusions

Casual blood pressure may overestimate blood pressure in stroke patients. Very old patients with stroke exhibit a mild increase in blood pressure during the acute phase, and blood pressure decreases spontaneously only in those with elevated blood pressure levels. Use of 24 h blood pressure monitoring may be helpful in elderly patients with acute stroke.

Severe hypertension in children and adolescents: pathophysiology and treatment

Severe, symptomatic hypertension occurs uncommonly in children, usually only in those with underlying congenital or acquired renal disease. If such hypertension has been long-standing, then rapid blood pressure reduction may be risky due to altered cerebral hemodynamics. While many drugs are available for the treatment of severe hypertension in adults, few have been studied in children. Despite the lack of scientific studies, some agents, particularly continuous intravenous infusions of nicardipine and labetalol, are preferred in many centers. These agents generally provide the ability to control the magnitude and rapidity of blood pressure reduction and should--in conjunction with careful patient monitoring--allow the safe reduction of blood pressure and the avoidance of complications. This review provides a summary of the underlying causes and pathophysiology of acute severe hypertension in childhood as well as a detailed discussion of drug treatment and the optimal clinical approach to managing children and adolescents with acute severe hypertension.

Common problems in critically ill obstetric patients, with an emphasis on pharmacotherapy

Pharmacological treatment of critically ill obstetric patients can be especially challenging due to the complexity of caring for 2 patients, with a paucity of research to support practice. This review will provide practitioners with primary recommendations for management of the critical illnesses most commonly encountered in pregnancy and will discuss the scientific and clinical merit of these recommendations.

Systemic hypertension

Hypertension is a growing public health problem worldwide. Only 37% of American hypertensives currently have their blood pressures controlled. Hypertension is traditionally diagnosed in the medical office, but both home and ambulatory blood pressure monitoring can help. Lifestyle modifications are recommended for everyone who has higher than "normal" blood pressure (<120/80 mm Hg). Voluminous clinical trial data support beginning drug therapy with low-dose chlorthalidone, unless the patient has a specific indication for a different drug. Additional drugs (typically in the sequence, angiotensin converting-enzyme inhibitor or angiotensin receptor blocker, calcium antagonist, beta-blocker, alpha-blocker, aldosterone antagonist, direct vasodilator, and centrally acting alpha(2)-agonist) can be added to achieve the blood pressure goal (usually <140/90 mm Hg, but <130/80 mm Hg for diabetics and those with chronic kidney disease). Special circumstances exist for treatment of hypertension in pregnancy, in childhood, in the elderly, and in both extremes of blood pressure (pre-hypertension or hypertensive emergencies).

Clinical Features and Management of Selected Hypertensive Emergencies

A hypertensive emergency, defined as an elevated blood pressure with evidence of acute target organ damage, can manifest in many forms, including neurological, cardiac, renal, and obstetric. After diagnosis, effective parenteral antihypertensive therapy (typically, nitroprusside starting at 0.5 microg/kg/min, but some physicians prefer fenoldopam or nicardipine) should be given in the hospital. In general, blood pressure should be reduced about 10% during the first hour and another 15% gradually over 2-3 more hours. The exception is aortic dissection, for which treatment includes a b blocker, and the target is systolic blood pressure <120 mm Hg after 20 minutes. Oral antihypertensive therapy can usually be instituted after 6-12 hours of parenteral therapy. Consideration should be given to secondary causes of hypertension after transfer from the intensive care unit. Because of advances in antihypertensive therapy and management, "malignant hypertension" should be malignant no longer.

Guidelines for the Early Management of Adults With Ischemic Stroke

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

Results— Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

PURPOSE

Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

METHODS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

RESULTS

Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Characteristics and management of patients presenting to the emergency department with hypertensive urgency

Few studies have examined the characteristics of patients presenting with hypertensive urgency, factors contributing to their presentation, or their management. The time and cost associated with treatment are unknown. Retrospective analysis of 50 emergency department patients with hypertensive urgency (symptomatic blood pressure (BP) elevation focusing on systolic BP >180 mm Hg or diastolic BP >110 mm Hg) was performed. The hospital database was queried to determine the cost of the average treat-and-release visit. The mean age was 54.3+/-15.6 years; 64% were female; 46% were black; 90% had diagnosed hypertension. The mean presenting BP was 198+/-27.6/109+/-17.3 mm Hg; 66% had systolic BP >180 mm Hg, and 38% had diastolic BP >110 mm Hg. Initially, 30% were not on antihypertensives, and 28% were on monotherapy. Headache (42%) and dizziness (30%) were most frequently reported symptoms. Presentation was most often attributed to running out of medication (16%). IV and oral labetalol were given to 28% and 24% of patients, respectively. Fifty-six percent of patients had no change in baseline therapy at discharge. The average emergency department stay was 5 hours 17 minutes +/- 4 hours 27 minutes. The average cost for similar visits in 2004 was 1543 dollars per visit. Emergency department visits for hypertensive urgency are related mostly to noncompliance. Labetalol was the most frequently used therapy. Management in the primary care office could result in substantial cost savings.

The assessment and management of hypertensive emergencies and urgencies in children

Although the prevalence of hypertension in the pediatric population is estimated at only 1% to 2%, hypertensive urgencies and emergencies may be encountered in the emergency department. Efficient management of these children is of utmost importance to avoid some of the life-threatening complications associated with hypertension and its treatment. This article serves to review some of the important aspects of pediatric hypertensive emergencies, including diagnosis, emergency department investigations, and pharmacologic management.

Clonidine Lowers Blood Pressure by Reducing Vascular Resistance and Cardiac Output in Young, Healthy Males

PURPOSE

Clonidine is a classical sympatholytic drug that is widely used for the treatment of hypertension. Experimental and clinical studies suggest that Clonidine may activate baroreflex. The aim of this study was to determine the hemodynamic response to Clonidine under physiological conditions and to test the hypothesis that Clonidine would reduce cardiac output and blood pressure resulting in an increase in total peripheral resistance.

METHODS

Clonidine's hemodynamic effect was evaluated in 28 young, healthy subjects after a single i.v. dose of 1 microg x kg(- 1). Impedance cardiography, systolic time intervals and pulse wave analysis were used to characterize myocardial and vascular function.

RESULTS

Clonidine lowered blood pressure, heart rate, left ventricular ejection time, and pulse wave velocity and increased pre-ejection period. Stroke volume and cardiac output decreased gradually over the investigation time of 240 min. Central systolic blood pressure (SBP) was lowered to a larger extent than peripheral SBP. Total peripheral resistance was characterized by an immediate fall of short duration followed by a continuous rise above baseline after 120 min. Placebo did not have any significant effect on hemodynamic parameters.

CONCLUSIONS

Clonidine's blood pressure lowering effect is mediated by both an immediate decrease in vascular resistance and a prolonged decrease in cardiac output, and Clonidine lowers central SBP more than peripheral SBP.

Management of hypertension emergencies

Although they have become less common, hypertensive emergencies occur with an incidence of approximately 1 to 2/100,000 people per year. Our knowledge about this problem, its pathophysiology, risk factors, and appropriate treatment options has expanded during the past decade. A hypertensive emergency can be declared when an elevated blood pressure is associated with acute target-organ damage. Rapid evaluation and treatment (typically with an intravenously administered agent) should be instituted, usually in an intensive care unit setting, and the patient should be observed carefully during acute blood-pressure lowering. When properly treated, the prognosis for these patients is not nearly as dismal as it was more than 60 years ago, and the initial level of function of target organs (brain, heart, kidneys) is more indicative of an emergency than the actual level of blood pressure. Therapeutic options include the time-tested sodium nitroprusside (which has toxic metabolic products and is contraindicated in pregnancy, tobacco amblyopia, and Leber's optic atrophy); fenoldopam mesylate; and nicardipine. When properly treated, "malignant hypertension" need be considered malignant no longer.

Severely increased blood pressure in the emergency department

Patients with severely increased blood pressure often present to the emergency department. Emergency physicians evaluate and treat hypertension in various contexts, ranging from the compliant patient with well-controlled blood pressure to the asymptomatic patient with increased blood pressure to the critically ill patient with increased blood pressure and acute target-organ deterioration. Despite extensive study and national guidelines for the assessment and treatment of chronically increased blood pressure, there is no clear consensus on the acute management of patients with severely increased blood pressure. In this article, we examine the broad spectrum of disease, from the asymptomatic to critically ill patient, and the dilemma it creates for the emergency physician in deciding how and when in the process to intervene.

Resistant hypertension, secondary hypertension, and hypertensive crises

Resistant hypertension, secondary hypertension, and hypertensive crises are uncommon but potentially dangerous forms of hypertension that are associated with an increased risk of complications such as myocardial infarction, heart failure, stroke, and renal failure. Appropriate diagnostic screening and selective drug or surgical management can reduce the risk of these complications dramatically. In compliant patients, resistant hypertension occurs most often in obese patients receiving inadequate diuretic therapy. In patients with clinical clues to the diagnosis, the best current screening test for renovascular hypertension is probably the ACE-inhibitor renal scintiscan. Angioplasty is considerably more successful in younger patients with fibrous dysplasia than in older patients with the atherosclerotic variety. Hypertensive crises are divided into BP urgencies and emergencies. In both settings, the reduction in BP should generally be gradual rather than abrupt, with no intent to acutely normalize the BP.

Evaluation of captopril for the management of hypertension in autonomic dysreflexia: a pilot study

OBJECTIVE

To evaluate the efficacy of captopril for management of hypertensive urgencies in autonomic dysreflexia.

DESIGN

A 1-year, prospective, open-label pilot study.

SETTING

Rehabilitation hospital.

PATIENTS

Twenty-six consecutive patients older than 15 years with spinal cord injury above T6.

INTERVENTIONS

During an autonomic dysreflexia episode, captopril 25mg was administered sublingually if systolic blood pressure (SBP) was at or above 150mmHg despite the use of nondrug measures. If SBP remained elevated 30 minutes after captopril administration, 1 dose of immediate-release nifedipine 5mg was given as rescue by the bite and swallow method and repeated, if necessary, in 15 minutes.

MAIN OUTCOME MEASURE

SBP 30 minutes after captopril administration at initial autonomic dysreflexia episode.

RESULTS

A total of 33 autonomic dysreflexia episodes were documented, of which 18 episodes in 5 patients were treated with drug therapy. Captopril alone was effective in 4 of 5 initial episodes (80%). Mean SBPs at baseline and 30 minutes after captopril were 178+/-18mmHg and 133+/-28mmHg, respectively. There were no cases of reactive hypotension. The addition of nifedipine successfully reduced SBP in the remaining patient. Of the combined 18 initial and repeat autonomic dysreflexia episodes, 94% were successfully treated with our protocol.

CONCLUSION

Captopril appears to be safe and effective for autonomic dysreflexia management.

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.

Effectiveness and safety of prehospital urapidil for hypertensive emergencies

The objective was to evaluate both the effectiveness and safety of urapidil in management of hypertensive emergencies (HE) in the prehospital setting. This was an open, prospective study for 6 months. We evaluated systolic (SBP), diastolic (DBP), and mean blood pressure (MBP), and heart rate (HR) with continuous noninvasive hemodynamic monitoring in 16 consecutive cases of HE. We used urapidil at different doses (25 to 100 mg) at 5 minute intervals, according to the blood pressure response. The basal DBP was 127 +/- 16 mmHg. Urapidil was effective in 15 patients. ANOVA test showed a significant drop out in DBP (P <.0001) and HR (P <.004). The highest decrease was obtained in the first 10 minutes. The decrease in DBP and HR values were significant at 5 minutes versus basal (P <.05) and at 10 versus 5 minutes (P <.01). All adverse effects had little relevance. Urapidil is effective and safe in management of HE when used by a medical team in the prehospital setting.

Hypertensive Crises

Despite the availability of effective antihypertensive agents, hypertensive crises still occur with relative frequency and remain an important therapeutic challenge. Hypertensive crises are defined as an abrupt elevation of blood pressure (BP) to a systolic BP reading of more than 210 mm Hg and a diastolic BP level of more than 120 mm Hg. The most important initial clinical decision is to differentiate between hypertensive urgency and hypertensive emergency. In both cases, therapy should be promptly initiated to prevent any permanent loss of organ function or life. The underlying pathophysiology and the intent to avoid adverse effects should guide the choice of antihypertensive agents. The most important principle to remember is to lower the blood pressure sufficiently to limit end-organ dysfunction, but without necessarily reaching normotensive levels. Additionally, it is always important to assess the fluid status of the patient and reestablish euvolemia as soon as feasible to avoid precipitous falls in blood pressure.