DOCSLIB.ORG

How to Handle Hypertension Crisis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
How to Handle Hypertension Crisis How to Handle Hypertension Crisis Learning Objectives 1. Define hypertensive crises: Hypertension urgency and hypertension emergency 2. Outline the pathophysiology of hypertensive urgencies and emergencies 3. Identify treatment goals and treatment options for hypertensive crises Faculty Karol E. Watson, MD, PhD, FACC Professor of Medicine/Cardiology, Co-director UCLA Program in Preventive Cardiology Director, UCLA Barbra Streisand Women’s Heart Health Program Professor of Medicine David Geffen School of Medicine at UCLA Los Angeles, California Slides are current as of the time of printing and may differ from the live presentation due to copyright issues. Please reference www.pri-med.com/west for the most up-to-date version of slide sets. West Annual Conference Anaheim, California April 27-30, 2016 Current State of Hypertensive Crisis Hypertension Emergencies in context Management • Hypertensive crises are among the most misunderstood and mismanaged acute medical problems seen in clinical practice Chronic Hypertension • Delays in initiating therapy can cause severe complications in target end organs Hypertension Urgencies • Overzealous therapy or too-rapid reduction in blood pressure may be equally damaging • Consideration of the pathophysiologic principles involved in hypertensive crises is of utmost importance Hypertension Emergencies Varon J, Marik PE. Chest. 2000;118:214-227. Epstein M. Clin Cornerstone. 1999;2:41-54. Hypertensive Urgencies / Terminology and Definitions Emergencies: (JNC 7) Urgency Emergency • Classification / Definition SevereThe Hypertension diagnosisplus of hypertensiveEnd-organ Damage • Etiology / Pathophysiology ► BPemergencies > 180/110 mm Hg depends► CHF on the • Evaluation clinical manifestations► ACS/AMI rather ► Renal failure • Management than only on the absolute level of ► Stroke and ICH • Follow up the blood pressure.► Encephalopathy ► Aortic dissection ► Pre-eclampsia ► Other? Hypertensive crisis Hypertensive Urgencies / Emergencies: • You will almost certainly see a hypertensive urgency in your career • Classification / Definition • You will also likely see a hypertensive • Etiology / Pathophysiology emergency - Only occur in 1-2% of the hypertensive population • Evaluation - But, there are 50 million hypertensive Americans • Management - 500,000 hypertensive emergencies/year • Follow up • Higher in the elderly and African Americans • Incidence is twice as high in men as compared to women Most Hypertensive Crises are Pathophysiology of Hypertensive caused by: Emergencies: a Vicious Cycle • Sodium excess Hypertensive Emergency Vasoconstriction, often • Extracellular volume expansion Circulating with intravascular vasoconstrictors • Sympathetic overactivation hypovolemia causes: End organ - Increased circulating ischemia Abrupt SVR catecholamines Too Much Sodium (Salt) - Activation of renin- Loss of angiotensin-aldosterone Abrupt BP system Too Much Water Autoregulatory - Altered autoregulatory function Too Much Sympathetic Activity Endothelial function damage Ault NJ, et al. Am J Emerg Med. 1985;3(6 suppl):10-15. 2. Wallach R, et al. Am J Cardiol. 1980;46:559-565. Varon J, et al. Chest. 2000;118:214-227. 4. Kincaid-Smith P. J Hypertens. 1991;9:893-899. Signs and Symptoms Signs and HTN Urgency (%) HTN Emergency (%) Symptoms Headache 22 3 How do patients with hypertensive Epistaxis 17 0 crises present? Chest Pain 927 Dyspnea 922 Faintness 10 10 Agitation 10 2 Neurologic Deficit 321 Vomiting 23 Arrhythmia 60 Zampaglione B, et al. Hypertension 1996;27:144-147. Signs and Symptoms Hypertensive Urgencies / Signs and HTN Urgency (%) HTN Emergency (%) Symptoms Emergencies: Headache 22 3 • Classification / Definition Epistaxis 17 0 • Etiology / Pathophysiology Chest Pain 927 Dyspnea • Evaluation 922 Goals of evaluation Faintness 10 10 • Management are to determine Agitation 10 2 • Outcomes etiology, and rapidly Neurologic Deficit 321 assess for end organ damage Vomiting 23 Arrhythmia 60 Zampaglione B, et al. Hypertension 1996;27:144-147. End-Organ Damage Characterizes Initial Evaluation Hypertensive Emergencies • Symptoms Brain Retina • Medical History Hypertensive Hemorrhages - Episodic palpitations and perspiration? encephalopathy Exudates Stroke Papilledema • Medications - MAO inhibitors Cardiovascular Kidney - Clonidine System Hematuria Unstable angina Proteinuria • Social History Acute heart failure Decreasing renal function - Recreational Drugs Acute myocardial infarction Amphetamines Acute aortic dissection Cocaine Dissecting aortic aneurysm Phencyclidine Adapted from Varon J, Marik PE. Chest. 2000;118:214-227. Physical Exam Hypertensive Retinopathy • Blood pressures must be taken in both arms Grade 1 – mild narrowing or sclerosis of retinal - If the cuff is too small, the BP will be falsely elevated arteries (arteriolar narrowing) - If the cuff is too low (below the level of the heart), the BP will be falsely elevated Grade 2 – moderate to marked arteriolar • Pulses should be checked in upper and lower narrowing with A-V crossing changes (AV extremities nicking) • Neuro exam Grade 3 – All the above + hemorrhages or • Cardiac exam cotton-wool spots • Pulmonary exam Grade 4 – All the above + additional swelling of • Ocular exam: only happens in 13% of pts the optic disk (papilledema) Labs / Imaging to consider Hypertensive Urgencies / Emergencies: • Comprehensive Metabolic Panel • Classification / Definition • CBC with peripheral smear (which may suggest microangiopathic hemolytic anemia). • Etiology / Pathophysiology • Urinalysis • Evaluation • EKG • Management • Chest X-ray • Outcomes • Head CT • Echocardiogram Elderly woman with hypertension • 78 year old woman with long- standing hypertension Management of Hypertensive • During a routine follow up Urgencies visit BP = 205 / 75 • No complaints except “not (BP > 180/110 mm Hg with NO end organ damage) feeling right”; fundi no visualized due to cataracts but otherwise normal exam • Admits to running out of her BP medications Goals of Therapy of Hypertensive Crises Elderly woman with hypertension • Hypertensive urgencies can generally be • 78 year old woman with managed with oral medications as an outpatient. chronic hypertension; BP = BP should be lowered over 24-48 hours 205 / 75; exam - normal - Important to prevent too-rapid lowering • Admitted to running out of her BP medications • Hypertensive emergencies must be treated as an • Placed in a quiet room and inpatient, usually in the ICU with intravenous administered usual meds medications. Goal is to reduce MAP by ~ 20% • 2 hours later BP 165/70; she within first hour felt well; normal exam - Some conditions, such as aortic dissection or hemorrhagic stroke require even more rapid reduction • Sent home on usual meds with home health JNC 7, JAMA 2003; 289:2560-2572 39 year old man with chest pain and shortness of breath • 39 year old male with chronic Management of Hypertensive substance abuse, renal failure Emergencies (on hemodialysis), and hypertension (BP > 180/110 mm Hg WITH end organ damage) • Missed last dialysis appointment and admits to current methamphetamine use • Presents to ED with severe chest pain and shortness of breath • BP 250/140 mm Hg 39 year old man with chest pain Presenting Symptoms and shortness of breath • Hypertensive Urgencies • CxR – CHF with pulmonary - vascular congestion Epistaxis - Headache • ECG – TW inversions inferiorly - Psychomotor agitation • Tn I – 0.11 (ULN 0.04) • DIAGNOSES: Hypertensive • Hypertensive Emergencies EMERGENCY due to: - Neurologic deficits - Missed HD, methamphetamine use, - Chest pain medication nonadherence - Dyspnea • Myocardial ischemia (NSTEMI) • Congestive heart failure Zampaglione et al, Hypertension 1996;27:144 How Low Should You Go? Hypertensive Encephalopathy • Simple answer - 20-25% reduction in MAP within 1st hour PRES: Posterior reversible encephalopathy syndrome • Better answer - It really depends on clinical condition Typically symmetrical white Less aggressive with ischemic stroke matter edema in the More aggressive with hemorrhagic stroke, posterior cerebral acute HF and aortic dissection hemispheres Marik and Varon. Critical Care 2003, 7:374-84. Cerebral Autoregulation Is Central to Autoregulation Treatment of Hypertensive Crises • In the uninjured, normotensive brain, autoregulation is Normal Regulatory effective over mean arterial pressure (MAP) of ~ 50 – (BP ~ 120/70 to 240/150) Cerebral Blood Flow Range 150 (that’s a BP ~ 80/40 to 190/130) (BP ~ 80/40 to 190/130) Increasing risk of • In chronic hypertension, this range isshifted upwards to hypertensive MAP 80 – 180 (BP ~ 120/70 to 240/150) encephalopathy Normotensive Chronic hypertensive • So, in the patients with out of control hypertension, if BP Increasing risk falls too rapidly to below ~120/70 cerebral perfusion can of ischemia be compromised 0 50 100 150200 250 MAP (mm Hg) All blood pressure sensitive organs have some degree of autoregulation Adapted from Varon J, Marik PE. Chest. 2000;118:214-227. Hypertensive Emergency: Goals of Other Important Points Therapy • • Immediate and controlled BP reduction ***ICU, ICU, ICU*** - Reduce BP 20-25% within minutes to 1 hour - Some studies suggest that only 15% of pts are admitted 1st line to an ICU - If BP is then stable, target toward 160/100-110 mm Hg over the next 2-6 hours • Once BP is stable, oral medications should be started as parenteral (IV) medications are titrated off - If this level of BP is well tolerated and the patient is clinically stable, further gradual reductions toward • Do not use sublingual nifedipine
Load more

Recommended publications
  • Hypertensive Emergency: an Overview of Heart As Target Organ Damage
    ORIGINAL ARTICLE Bali Medical Journal (Bali Med J) 2020, Volume 9, Number 3: 903-906 P-ISSN.2089-1180, E-ISSN: 2302-2914 Hypertensive emergency: an overview of heart as target organ damage Starry Homenta Rampengan1*, H J Sunarto2 ABSTRACT Hypertension is currently still a global problem in the cardiology cells’ death affected heart structure and its function. The symptoms and vascular fields with an increasing trend. One of the emergency that appear can be in the form of acute coronary syndrome or acute conditions related to an increase in blood pressure is emergency heart failure. Some modalities can detect heart structure changes, hypertension. Emergency hypertension is a condition where blood like electrocardiography for general and echocardiography for pressure rises rapidly and severely, resulting in new or progressive specific examination. Hypertensive emergencies can be treated organ damage. Symptoms can range from chest pain, shortness by several rapid-acting antihypertensive agents, which can be of breath to delirium. The heart is one of the organs that can be selected based on the clinical manifestations. As the symptoms damaged by hypertensive emergencies. The availability and related to heart damage are acute coronary syndrome and acute demand for oxygen from the coronary blood vessels to the heart heart failure, so the treatment will be specific, respectively. Good muscle cells will experience an imbalance due to a sudden increase knowledge related to emergency hypertension management and in blood pressure. Lack of oxygen that occurs can cause heart muscle early treatment will reduce patient morbidity. Keywords: hypertensive emergency, heart, organ damage Cite this Article: Rampengan, S.H., Sunarto, H.J.
    [Show full text]
  • Life-Threatening Events in Patients with Pheochromocytoma
    A Riester and others Life-threatening events in 173:6 757–764 Clinical Study pheochromocytoma Life-threatening events in patients with pheochromocytoma Anna Riester, Dirk Weismann1, Marcus Quinkler2, Urs D Lichtenauer3, Sandra Sommerey4, Roland Halbritter5, Randolph Penning6, Christine Spitzweg7, Jochen Schopohl, Felix Beuschlein and Martin Reincke Medizinische Klinik und Poliklinik IV, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Ziemssenstr. 1, D-80336 Munich, Germany, 1Medizinische Klinik und Poliklinik I, Universita¨ tsklinikum Wu¨ rzburg, Correspondence Wu¨ rzburg, Germany, 2Endokrinologie in Charlottenburg, Berlin, Germany, 3Helios Klinik Schwerin, Schwerin, should be addressed Germany, 4Chirurgische Klinik und Poliklinik – Innenstadt, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians- to M Reincke Universita¨ tMu¨ nchen, Munich, Germany, 5Facharztpraxis, Pfaffenhofen, Germany, 6Institut fu¨ r Rechtsmedizin and Email 7Medizinische Klinik und Poliklinik II, Klinikum der Universita¨ tMu¨ nchen, Ludwig-Maximilians-Universita¨ t, Munich, martin.reincke@ Germany med.uni-muenchen.de Abstract Objective: Pheochromocytomas are rare chromaffin cell-derived tumors causing paroxysmal episodes of headache, palpitation, sweating and hypertension. Life-threatening complications have been described in case reports and small series. Systematic analyses are not available. We took an opportunity of a large series to make a survey. Design and methods: We analyzed records of patients diagnosed with pheochromocytomas in three geographically spread German referral centers between 2003 and 2012 (nZ135). Results: Eleven percent of the patients (ten women, five men) required in-hospital treatment on intensive care units (ICUs) due to complications caused by unsuspected pheochromocytomas. The main reasons for ICU admission were acute catecholamine induced Tako-Tsubo cardiomyopathy (nZ4), myocardial infarction (nZ2), acute pulmonary edema (nZ2), cerebrovascular stroke (nZ2), ischemic ileus (nZ1), acute renal failure (nZ2), and multi organ failure (nZ1).
    [Show full text]
  • Therapy Management Guide
    INLYTA® (axitinib) + pembrolizumab THERAPY MANAGEMENT GUIDE Dosing recommendations and management strategies when INLYTA is used in combination with pembrolizumab for the first-line treatment of advanced RCC When INLYTA is used in combination with pembrolizumab, please refer to the full Prescribing Information for pembrolizumab for full dosing and AR management information INDICATION INLYTA in combination with pembrolizumab is indicated for the first-line treatment of patients with advanced renal cell carcinoma (RCC). IMPORTANT SAFETY INFORMATION Hypertension including hypertensive crisis has been observed. Blood pressure should be well controlled prior to initiating LIN YTA. Monitor for hypertension and treat as needed. For persistent hypertension despite use of antihypertensive medications, reduce the dose. Discontinue INLYTA if hypertension is severe and persistent despite use of antihypertensive therapy and dose reduction of INLYTA, and discontinuation should be considered if there is evidence of hypertensive crisis. Arterial and venous thrombotic events have been observed and can be fatal. Use with caution in patients who are at increased risk for, or who have a history of, these events. Hemorrhagic events, including fatal events, have been reported. INLYTA has not been studied in patients with evidence of untreated brain metastasis or recent active gastrointestinal bleeding and should not be used in those patients. If any bleeding requires medical intervention, temporarily interrupt the INLYTA dose. Please see additional Important
    [Show full text]
  • Hypertensive Emergency)
    Hypertensive Crisis Adj Asst Prof Ashish Anil Sule, Senior Consultant, GM, Vascular Medicine and hypertension MD, MRCP, FRCP, FAMS, ESH specialist Overview • Case • Definition - Urgency/ Emergency and others • Evaluation, diagnosis and approach – 1. How quickly to reduce blood pressure 2. Is there any BP target 3. How should this goal be achieved • Treatment with intravenous anti-hypertensive and conditions Question 1 30 years old gentleman, presented to emergency for hypertensive urgency with severe chest pain. He was diagnosed to have aortic dissection. Which is the first line of treatment for this patient ? • Intravenous Nitroglycerine • Intravenous Labetelol • Intravenous Nitroprusside • Intravenous Phentolamine • Oral Captopril Question 2 What should be his target blood pressure and within how much time this should be achieved: • Lower BP to 100-120 mm Hg within 20 minutes • Lower BP to 120-140 mm Hg within 40 minutes • Lower BP to 140-160 mm Hg within 20 minutes • Lower BP to 140-160 mm Hg within 40 minutes Question 3 45 years old gentleman, known case of hypertension presented with sudden loss of consciousness. O/E- BP 200/120 mm Hg, patient was drowsy. CT brain showed evidence of cerebellar bleed. Which is the ideal choice of anti-hypertensive ? • IV nitroprusside • IV Nitroglycerine • IV Nicardipine • IV Phentolamine • Oral captopril Question 4 In the same patient : what target of systolic BP should be achieved • <140 mm Hg • <160 mm Hg • <180 mm Hg • <200 mm Hg • None of the above GRR Past Medical History 71 years female 1. Resistant Hypertension secondary Indian, to right renal stenosis ADL independent - s/p Right artery stenting 22/3/16 community ambulant 2.
    [Show full text]
  • Hypertensive Crisis in Modern Guidelines: How to Avoid Mistakes in Diagnosis and Treatment
    Архивъ внутренней медицины • № 6 • 2019 ЛЕКЦИИ DOI: 10.20514/2226-6704-2019-9-6-407-412 UDC: 616.12-008.331.1-07-08 Yu. V. Evsyutina Federal State Budgetary Institution National Medical Research Center for Preventive Medicine of the Ministry of Health of Russia, Moscow, Russia HYPERTENSIVE CRISIS IN MODERN GUIDELINES: HOW TO AVOID MISTAKES IN DIAGNOSIS AND TREATMENT. BASED ON THE MATERIALS OF THE RUSSIAN NATIONAL «HUMAN AND MEDICINE» CONGRESS AND THE III CARDIOLOGY SUMMIT Abstract The prevalence of hypertension is about 40 % according to Russian and world statistics. Approximately 1–2 % of patients with hypertension have high blood pressure throughout their lives, which requires urgent or emergency care. Hypertensive crisis is an acute condition caused by a sudden increase in blood pressure to individually high values, accompanied by clinical symptoms and requiring a controlled reduction to prevent target organ damage. According to the severity of clinical symptoms, hypertensive crisis is divided into uncomplicated and complicated. Typical signs of hypertensive crisis include malignant hypertension, severe hypertension associated with other clinical conditions, a sudden increase in blood pressure due to pheochromocytoma associated with organ damage, severe hypertension during pregnancy or preeclampsia. Hypertensive crisis is associated with various acute conditions, most often stroke (ischemic and hemorrhagic), acute cardiogenic pulmonary edema, acute heart failure, acute coronary syndrome, acute kidney injury, acute aortic dissection and eclampsia. The main goals of the treatment of hypertensive crisis are relief of the crisis, post-crisis stabilization, and prevention of repeated hypertensive crises. In patients with an uncomplicated hypertensive crisis, a decrease in mean blood pressure by 10 % during the first hour and by another 15 % during the next 2–3 hours is recommended.
    [Show full text]
  • Pulmonary Hypertension in the Intensive Care Unit
    Pulmonary vascular disease ORIGINAL ARTICLE Heart: first published as 10.1136/heartjnl-2015-307774 on 6 April 2016. Downloaded from Pulmonary hypertension in the intensive care unit. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK Michael Kaestner,1 Dietmar Schranz,2 Gregor Warnecke,3,4 Christian Apitz,1 Georg Hansmann,5 Oliver Miera6 For numbered affiliations see ABSTRACT heterogeneous underlying conditions.1 Distinction end of article. Acute pulmonary hypertension (PH) complicates the between precapillary and postcapillary aetiologies Correspondence to course of several cardiovascular, pulmonary and other (or establishment of a combination of the two) is Dr. Oliver Miera, Department systemic diseases in children. An acute rise of RV important to initiate specific individual therapy. of Congenital Heart Disease afterload, either as exacerbating chronic PH of different and Paediatric Cardiology, aetiologies (eg, idiopathic pulmonary arterial Pathophysiology of acute PH and RV failure Deutsches Herzzentrum Berlin, hypertension (PAH), chronic lung or congenital heart Augustenburger Platz 1, Chronic PH causes adaptation and remodelling of Berlin 13353, Germany; disease), or pulmonary hypertensive crisis after corrective the RV to increased loading conditions. Pulmonary [email protected] surgery for congenital heart disease, may lead to severe hypertensive crisis (PHC) occurs when compensatory circulatory compromise. Only few clinical studies provide mechanisms fail, RV systolic function decompensates This manuscript is a product of evidence on how to best treat children with acute severe and LV preload acutely decreases resulting in abol- the writing group of the 23 European Paediatric Pulmonary PH and decompensated RV function, that is, acute RV ished cardiac output and coronary perfusion.
    [Show full text]
  • Management of Hypertensive Emergencies Jaya Mallidi, Srikanth Penumetsa and Amir Lotfi* the Division of Cardiology, Baystate Medical Center, USA
    ns erte ion p : O y p Mallidi et al., J Hypertens 2013, 2:2 H e f n o l A 2167-1095 a c DOI: 10.4172/ .1000117 c n r e Journal of Hypertension: Open Access u s o s J ISSN: 2167-1095 ResearchCommentary Article OpenOpen Access Access Management of Hypertensive Emergencies Jaya Mallidi, Srikanth Penumetsa and Amir Lotfi* The Division of Cardiology, Baystate Medical Center, USA Abstract Hypertension is a common problem encountered in everyday clinical practice. Patients with poorly controlled hypertension may present to the emergency room with “hypertensive emergency” - severely elevated blood pressure (>180/120 mmHg) associated with end organ damage, involving neurological, cardiovascular or renal systems. There is a paucity of literature regarding the preferred rate of decline of blood pressure, while treating these patients, as well as the appropriate medications to be used. Based on expert opinion and anecdotal data, it is recommended that the initial management should focus on promptly identifying impending or established end organ damage and decreasing the blood pressure by about 25% in the first 2 hours, except in aortic dissection where rapid lowering of blood pressure is recommended. This review provides a focused approach to the management of hypertensive emergencies. Keywords: Hypertension; Emergency; Urgency physical examination should be performed and appropriate treatment strategies should be employed to address the underlying cause. Introduction History Hypertension is a common problem affecting 60-70 million people in the United States [1]. Two thirds of patients are unaware All patients with presenting with severe hypertension should that they have hypertension [2].
    [Show full text]
  • Hypertensive Crisis
    Review: Hypertensive crisis Hypertensive crisis Ker JA, MBChB, MMed(Int), MD, Deputy Dean, Senior Specialist Department of Internal Medicine Faculty of Health Sciences, University of Pretoria Correspondence to: James Ker, e-mail: [email protected] Keywords: hypertension, crisis © Medpharm S Afr Fam Pract 2011;53(3):251-253 Background and definition Common associations with hypertensive crisis Hypertension is a common medical problem. It affects approximately one in four adults worldwide, with evidence Several blood pressure elevations can develop de novo, that the prevalence is rising. In the USA, approximately 30% or complicate essential hypertension or secondary of adults have some form of hypertension.1 It is estimated hypertension. Common causes of a severe elevation in blood that 1-2% of the hypertensive population will present pressure can be seen in Table I. The exact pathophysiology with an acute and severe elevation of blood pressure at and the exact reasons why some hypertensive patients some stage, i.e. hypertensive crisis: systolic blood pressure will develop myointimal-proliferation fibrinoid necrosis, 5 > 180 mmHg, or diastolic blood pressure > 120 mmHg.2 and a hypertensive crisis, are unknown. An abrupt rise in blood pressure causes endothelial injury, activation of 3 A hypertensive crisis is further divided into: platelets and coagulation and fibrinoid necrosis. The renin- • Hypertensive emergency: The elevated blood pressure angiotensin system is often stimulated and contributes to poses an immediate threat to the integrity of the vasoconstriction. Other contributing factors are volume cardiovascular system, and there is end-organ damage or depletion due to pressure natriuresis, and catecholamine evidence of ongoing end-organ damage, e.g.
    [Show full text]
  • Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: a Narrative Review
    brain sciences Review Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review Mariagiovanna Cantone 1 , Giuseppe Lanza 2,3,* , Valentina Puglisi 4, Luisa Vinciguerra 4, Jaime Mandelli 5, Francesco Fisicaro 6 , Manuela Pennisi 6, Rita Bella 7 , Rosella Ciurleo 8 and Alessia Bramanti 8 1 Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy; [email protected] 2 Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy 3 Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy 4 Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; [email protected] (V.P.); [email protected] (L.V.) 5 Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy; [email protected] 6 Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; drfrancescofi[email protected] (F.F.); [email protected] (M.P.) 7 Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy; [email protected] 8 IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; [email protected] (R.C.); [email protected] (A.B.) * Correspondence: [email protected] or [email protected]; Tel.: +39-095-3782448 Abstract: Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and Citation: Cantone, M.; Lanza, G.; early target, among others.
    [Show full text]
  • Hypertensive Crises: Diagnosis and Management in the Emergency Room
    European Review for Medical and Pharmacological Sciences 2004; 8: 143-152 Hypertensive crises: diagnosis and management in the emergency room A. MIGNECO, V. OJETTI, A. DE LORENZO**, N. GENTILONI SILVERI, L. SAVI* Dept. of Emergency Medicine, Catholic University - Rome (Italy) *Dept. of Internal Medicine, Catholic University - Rome (Italy) **Human Nutrition Unit, University of Tor Vergata - Rome (Italy) Abstract. – Hypertensive crises are com- by the absolute BP levels, but also by the monly observed in an emergency room. magnitude and the rate of the pressure in- Regardless blood pressure values, hyperten- crease and by the underlying conditions3,4. sive crises are classified in emergencies, char- acterized by life-threatening acute organ dam- For instance, blood pressure levels in eclamp- age, and urgencies, with no evidence of acute sia may be only slightly elevated; neverthe- or progressive organ injury. In an hypertensive less, immediate treatment of hypertension in emergency an appropriate and immediate man- this setting is mandatory. agement with parenteral drugs is mandatory, Hypertensive crises are traditionally subdi- while in an hypertensive urgency blood pres- vided in hypertensive emergencies and ur- sure should be decreased within 24-48 h with 5-7 orally active agents. gencies . This article reviews the spectrum of clinical The presence of acute or progressive life syndromes that comprise hypertensive emer- threatening organ damage such as acute coro- gencies, focusing on specific drugs and thera- nary syndrome, acute left ventricular failure peutic strategies available in the emergency with pulmonary oedema, eclampsia, aortic department, based on current literature. dissection, acute renal failure, hypertensive Since no randomized prospective trials are encephalopathy and haemorragic/ischaemic available, an evidence-based approach recom- mending an optimal therapeutical management stroke constitutes an hypertensive emer- 5-7 is not possible.
    [Show full text]
  • Nexavar, INN-Sorafenib
    ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS 1 1. NAME OF THE MEDICINAL PRODUCT Nexavar 200 mg film-coated tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each film-coated tablet contains 200 mg of sorafenib (as tosylate). For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM Film-coated tablet (tablet). Red, round, biconvex film-coated tablets, debossed with Bayer cross on one side and "200" on the other side. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Hepatocellular carcinoma Nexavar is indicated for the treatment of hepatocellular carcinoma (see section 5.1). Renal cell carcinoma Nexavar is indicated for the treatment of patients with advanced renal cell carcinoma who have failed prior interferon-alpha or interleukin-2 based therapy or are considered unsuitable for such therapy. Differentiated thyroid carcinoma Nexavar is indicated for the treatment of patients with progressive, locally advanced or metastatic, differentiated (papillary/follicular/Hürthle cell) thyroid carcinoma, refractory to radioactive iodine. 4.2 Posology and method of administration Nexavar treatment should be supervised by a physician experienced in the use of anticancer therapies. Posology The recommended dose of Nexavar in adults is 400 mg sorafenib (two tablets of 200 mg) twice daily (equivalent to a total daily dose of 800 mg). Treatment should continue as long as clinical benefit is observed or until unacceptable toxicity occurs. Posology adjustments Management of suspected adverse drug reactions may require temporary interruption or dose reduction of sorafenib therapy. 2 When dose reduction is necessary during the treatment of hepatocellular carcinoma (HCC) and advanced renal cell carcinoma (RCC), the Nexavar dose should be reduced to two tablets of 200 mg sorafenib once daily (see section 4.4).
    [Show full text]
  • Management of Hypertensive Emergencies
    Management of Hypertensive Emergencies Keywords: Hypertension; Emergency; Urgency physical examination should be performed and appropriate treatment strategies should be employed to address the underlying cause. Introduction History Hypertension is a common problem afecting 60-70 million people in the United States [1]. Two thirds of patients are unaware All patients with presenting with severe hypertension should that they have hypertension [2]. While it is well known that poorly controlled hypertension is a major risk factor for cardiovascular and cerebrovascular mortality, acute severe elevation in the blood pressure can also cause acute end organ damage. Approximately 1-2% of all the hypertensive patients present to the emergency room with hypertensive emergency at least once in their lifetime [3]. Given the high prevalence of hypertension in our society, hypertensive emergencies are commonly encountered in everyday clinical practice [3]. Prompt recognition, evaluation and treatment are of paramount importance in preventing permanent end organ damage. Te most recent periodic review by the Joint National Committee (JNC) on “Prevention, Detection, Evaluation and Treatment of High Blood Pressure”, does not give explicit guidelines on the management of hypertensive emergencies [4]. Tis review article aims to discuss the management of hypertensive emergencies based on specifc clinical situations. Defnition JNC 7 classifes blood pressure into diferent categories (Table 1) [4]. Hypertensive emergency is defned as “a severe elevation is blood pressure (usually >180/120 mmHg) complicated by impending or progressive target organ dysfunction involving neurological, cardiac or renal systems” [4]. Common clinical manifestations of end organ damage in hypertensive emergency include Acute Coronary Syndrome (ACS), acute decompensated heart failure, encephalopathy, intracerebral hemorrhage and acute renal failure.
    [Show full text]