Clinical trial update: New paradigm in management of acute hypertension
Acute and chronic hypertension: Clinical context Chronic hypertension Hypertensive emergencies Acute vascular reactivity Courtesy of S Aronson, MD.
Sympathetic overactivation drives acute hypertension Calhoun DA, Oparil S. N Engl J Med. 1990;323:1177-83. Cheung AT. J Card Surg. 2006;21(suppl):S8-14. Weitz HH. Med Clin North Am. 2001;85:1151-69. Sympathetic overactivation Acute hypertension Arteriosclerosis Chronic hypertension Important triggers include clonidine withdrawal, cocaine abuse, certain surgical settings
FLOW PRESSURE HR x SV = CO BP*/ CO = SVR CO x MAP = work MAP = 1/3 PP + DBP All in the absence of pulsations Components of blood pressure: New focus on pulse pressure Courtesy of S Aronson, MD.
Perioperative ISH associated with postoperative adverse events Aronson S et al. Anesth Analg . 2002;94:1079-84. N = 2069 scheduled for CABG ISH = isolated systolic hypertension 1.4 (1.1-1.7) 40.9 33.2 Renal failure/insufficiency, stroke, LV dysfunction, death 1.3 (1.0-1.6) 34.3 29.1 LV dysfunction 1.7 (1.2-2.3) 10.1 6.3 Stroke 1.3 (0.9-1.9) 8.8 6.7 Renal failure/insufficiency ISH (n = 612) No ISH (n = 1457) Odds ratio Event rate (%)
Proposed risk index for renal dysfunction/failure post-CABG: Importance of pulse pressure Aronson S et al. Circulation . 2007;115:733-42. N = 4801 scheduled for bypass Multicenter Study of Perioperative Ischemia (McSPI) 15 6 10 Score Intra-aortic balloon pump Cardiopulmonary bypass ≥122 min >2 Inotropes Intraoperative risk factors 9 6 13 History CHF MI Renal disease 0 4 8 12 16 Pulse pressure (mm Hg) 40 41-60 61-80 81-100 >100 7 Age >75 years Score Preoperative risk factors
Acute hypertension: Subgroups and settings Acute hypertension Hypertensive urgency Hypertensive emergency Perioperative hypertension Operating room Postanesthesia care Emergency department Intensive care unit
JNC 7 definitions Chobanian AV et al. Hypertension. 2003;42:1206-52. Severe elevation in BP without progressive end-organ damage Hypertensive urgency BP >180/120 mm Hg complicated by evidence of impending or progressive end-organ damage Hypertensive emergency
Hypertensive urgencies/emergencies: Patients and organ systems at risk
Acute pulmonary edema
Acute aortic syndromes
Acute renal dysfunction
Calhoun DA, Oparil S. N Engl J Med. 1990;323:1177-83. Marik PE, Varon J. Chest. 2007;131:1949-62. ACS = acute coronary syndrome ADHF = acute decompensated heart failure 1% of hypertensives (1990 data). Contemporary prevalence may be lower
Hypertensive urgencies/emergencies: Prevalence of organ system complications N = 449 presenting to Emergency Department with hypertensive urgency/emergency Zampaglione B et al. Hypertension. 1996;27:144-7. Incidence (%) 2.0 Aortic dissection 4.5 Eclampsia 12.0 ACS 14.3 Acute congestive heart failure 22.5 Pulmonary edema CV 4.5 Intracerebral/subarachnoid hemorrhage 16.3 Hypertensive encephalopathy 24.5 Cerebral infarction CNS
Hypertensive urgencies/emergencies: Most common presenting symptoms
Faintness and psychomotor agitation (10%)
Chest pain (27%)
Neurological deficit (21%)
Zampaglione B et al. Hypertension. 1996;27:144-7.
Perioperative hypertension: Scope of the problem
Generally acknowledged to be common but little data available on exact prevalence in contemporary surgical practice
Markers of increased risk for perioperative ↑BP include:
History of hypertension
Type of surgery
Skarvan K. Curr Opin Anaesthesiol. 1998;11:29-35. Weitz HH. Med Clin North Am. 2001;85:1151-69. Erstad BL, Barletta JF. Ann Pharmacother. 2000;34:66-79.
Perioperative antihypertensive therapy is common in cardiac surgery Vuylsteke A et al. J Cardiothorac Vasc Anesth. 2000;14:269-73. N = 1660 patients, (N = 191 anesthesiologists) Mean MAP threshold for treatment (mm Hg) 106.0 86.3 97.1 109.0