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Vascular Dysfunction: Sequelae of Acute Hypertension
Overview <ul><li>Introduction: Scope of the problem </li></ul><ul><li>Effects of acute BP elevation on the vessel wall </l...
Acute and chronic hypertension: Clinical context Chronic  hypertension Hypertensive emergencies Acute  vascular  reactivit...
Sympathetic overactivation drives acute hypertension Calhoun DA, Oparil S.  N Engl J Med.  1990;323:1177-83. Cheung AT.  J...
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...
Perioperative ISH associated with postoperative adverse events Aronson S et al.  Anesth Analg . 2002;94:1079-84. N = 2069 ...
Proposed risk index for renal dysfunction/failure post-CABG: Importance of pulse pressure Aronson S et al.  Circulation . ...
Acute hypertension:  Subgroups and settings Acute hypertension Hypertensive  urgency Hypertensive emergency Perioperative ...
JNC 7 definitions Chobanian AV et al.  Hypertension.  2003;42:1206-52. Severe elevation in BP without progressive end-orga...
Hypertensive urgencies/emergencies:  Patients and organ systems at risk <ul><li>Cardiopulmonary </li></ul><ul><li>ADHF </l...
Hypertensive urgencies/emergencies: Prevalence of organ system complications N = 449 presenting to Emergency Department wi...
Hypertensive urgencies/emergencies:  Most common presenting symptoms <ul><li>Urgencies </li></ul><ul><li>Headache (22%) </...
Perioperative hypertension:  Scope of the problem <ul><li>Generally acknowledged to be common but little data available on...
Perioperative antihypertensive therapy is common in cardiac surgery Vuylsteke A et al.  J Cardiothorac Vasc Anesth.  2000;...
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  1. 1. Vascular Dysfunction: Sequelae of Acute Hypertension
  2. 2. Overview <ul><li>Introduction: Scope of the problem </li></ul><ul><li>Effects of acute BP elevation on the vessel wall </li></ul><ul><li>Traditional parenteral antihypertensive treatment </li></ul><ul><ul><li>Pharmacokinetic profiles and key clinical studies </li></ul></ul><ul><ul><li>Guidelines for use </li></ul></ul><ul><li>Clinical trial update: New paradigm in management of acute hypertension </li></ul>
  3. 3. Acute and chronic hypertension: Clinical context Chronic hypertension Hypertensive emergencies Acute vascular reactivity Courtesy of S Aronson, MD.
  4. 4. 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
  5. 5. 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.
  6. 6. 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 (%)
  7. 7. 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
  8. 8. Acute hypertension: Subgroups and settings Acute hypertension Hypertensive urgency Hypertensive emergency Perioperative hypertension Operating room Postanesthesia care Emergency department Intensive care unit
  9. 9. 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
  10. 10. Hypertensive urgencies/emergencies: Patients and organ systems at risk <ul><li>Cardiopulmonary </li></ul><ul><li>ADHF </li></ul><ul><li>ACS </li></ul><ul><li>Acute pulmonary edema </li></ul><ul><li>Acute aortic syndromes </li></ul><ul><li>Neurovascular </li></ul><ul><li>Hypertensive encephalopathy </li></ul><ul><li>Stroke </li></ul><ul><li>Ocular </li></ul><ul><li>Papilloedema </li></ul><ul><li>Renal </li></ul><ul><li>Acute renal dysfunction </li></ul>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
  11. 11. 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
  12. 12. Hypertensive urgencies/emergencies: Most common presenting symptoms <ul><li>Urgencies </li></ul><ul><li>Headache (22%) </li></ul><ul><li>Epistaxis (17%) </li></ul><ul><li>Faintness and psychomotor agitation (10%) </li></ul><ul><li>Emergencies </li></ul><ul><li>Chest pain (27%) </li></ul><ul><li>Dyspnea (22%) </li></ul><ul><li>Neurological deficit (21%) </li></ul>Zampaglione B et al. Hypertension. 1996;27:144-7.
  13. 13. Perioperative hypertension: Scope of the problem <ul><li>Generally acknowledged to be common but little data available on exact prevalence in contemporary surgical practice </li></ul><ul><li>Markers of increased risk for perioperative ↑BP include: </li></ul><ul><ul><li>History of hypertension </li></ul></ul><ul><ul><li>Type of surgery </li></ul></ul><ul><ul><ul><li>Cardiac </li></ul></ul></ul><ul><ul><ul><li>Carotid </li></ul></ul></ul><ul><ul><ul><li>Peripheral vascular </li></ul></ul></ul><ul><ul><ul><li>Abdominal aortic </li></ul></ul></ul><ul><ul><ul><li>Intraperitoneal/intrathoracic </li></ul></ul></ul><ul><ul><ul><li>Pheochromocytoma tumor </li></ul></ul></ul>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.
  14. 14. 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
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