Core Curriculum

• Vascular Dysfunction: Sequelae of Acute Hypertension

VBWG08_AH.pdf (1.4MB)VBWG08_AH.pdf (1.4MB)

Vascular Dysfunction: Sequelae of Acute Hypertension

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Vascular Dysfunction: Sequelae of AcuteHypertension Overview Acute and chronic hypertension: Clinical context Sympathetic overactivation drives acute hypertension Components of blood pressure: New focus on pulse pressure Perioperative ISH associated with postoperative adverse events Proposed risk index for renal dysfunction/failure post-CABG: Importance of pulse pressure Acute hypertension: Subgroups and settings JNC 7 definitions Hypertensive urgencies/emergencies: Patients and organ systems at risk Hypertensive urgencies/emergencies: Prevalence of organ system complications Hypertensive urgencies/emergencies: Most common presenting symptoms Perioperative hypertension: Scope of the problem Perioperative antihypertensive therapy is common in cardiac surgery

Effects of Acute BP Elevation on the Vessel Wall

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Effects of AcuteBP Elevation onthe Vessel Wall Pathophysiology overview Pathophysiology of hypertension The endothelium modulates vascular tone Proposed vascular pathophysiology of hypertensive urgency Proposed vascular pathophysiology of hypertensive emergency Endothelial shear stress Endothelial mechanoreceptors sense changes in shear stress Shear stress rapidly activates endothelial signal transduction and gene expression Definition and example of pulsatile, low, and oscillatory ESS Implications of low and high shear stress Perioperative triggers of adverse physiologic states Proposed mechanisms of perioperative MI Summary: The pathophysiology of acute hypertensive syndromes Pathophysiology of acute hypertensive syndromes: A vicious cycle Summary: Acute hypertension Acute hypertension: Conclusions


Download VBWG08_AH3.ppt (13 slides - 0.9MB)

Slide 1 Treatment choice should be based on each patient’s presentation and specific to underlying conditions and the organ at risk. Ideally, the antihypertensive should have: A number of parenteral antihypertensive options are available, offering a range of onset and duration of action. Sodium nitroprusside is a nonselective vasodilator and is the most rapid acting of available parenteral BP-lowering treatments. Esmolol is a relatively cardioselective beta-blocker, with a rapid onset and an intermediate duration of action. Fenoldopam was the last antihypertensive to be approved for parenteral use in this country. Slide 7 Intravenous dihydropyridine calcium channel blockers are attractive options for use in acute hypertension, since they produce arterial vasodilation without negative inotropic (contraction) or dromotropic (conduction) effects. The response to IV nicardipine in a female patient is shown. The results of this study demonstrated that intravenous nicardipine was as effective as SNP in reducing BP in both noncardiac and cardiac surgery patients. Study subjects (N = 183, n = 153 with evaluable data) were randomized to sodium nitroprusside (SNP) or fenoldopam. Diastolic blood pressure (DBP) was titrated to           95 mm Hg to 110 mm Hg, with a maximum reduction of 40 mm Hg. Fenoldopam increases renal blood flow. Some data suggest that this drug may protect against postoperative renal dysfunction. Slide 13


Download VBWG08_AH4.ppt (6 slides - 0.6MB)

Slide 1 BP-lowering treatments are being studied in the setting of acute hypertension. The first-generation agents were exemplified by nifedipine, which was administered orally or sublingually. Clevidipine is a new, ultrashort-acting parenteral dihydropyridine calcium channel blocker (CCB) that does not cause reflex tachycardia. At steady state in healthy volunteers, there is a linear relationship between dosage and arterial blood concentrations. The linear relationship is maintained for dose rates as high as 7 nmol/kg per min. Nesiritide is a recombinant B-type natriuretic peptide with venous and arterial vasodilatory effects.

Management of Hypertensive Emergencies

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Management of Hypertensive Emergencies New paradigm in treatment of acute hypertension Hypertensive urgencies/emergencies: Issues VELOCITY: Study design VELOCITY: Clevidipine in acute hypertension PROACTION: Effects of Nesiritide on BP Limited data on other parenteral antihypertensives for hypertensive emergencies Follow-up care in hypertensive emergencies STAT Registry: Addressing knowledge gaps in contemporary acute hypertension STAT: Design STAT: Exclusion criteria STAT: Sources of antihypertensive management data


Download VBWG08_AH8.ppt (13 slides - 0.9MB)

Slide 1 ESCAPE (Efficacy Study of Clevidipine Assessing its Perioperative Antihypertensive Effect in Cardiac Surgery) consists of two placebo-controlled trials with the same efficacy measures. Clevidipine was administered for at least 30 minutes and up to 1 hour before anesthesia induction in this trial. Results of both ESCAPE-1 and ESCAPE-2 were presented at the 56th Annual Meeting of the American Society of Anesthesiologists, 2007. The ECLIPSE (Evaluation of Clevidipine in the Perioperative Treatment of Hypertension Assessing Safety Events) program is addressing gaps in the evidence base regarding perioperative BP control. Event rates for safety endpoints were similar in clevidipine and comparator groups in the individual arms of ECLIPSE. Similar safety event rates were also observed when safety data for the clevidipine and comparator groups were combined. ECLIPSE investigators measured BP excursions above or below prespecified SBP limits. Clevidipine was associated with significantly better BP control than nitroglycerin and sodium nitroprusside, and with comparable BP control as nicardipine. Multiple logistic regression analysis was used to estimate the risk for different degrees of BP control. Further analysis of the ECLIPSE data showed that BP control was an independent risk factor for 30-day renal dysfunction (defined as a creatinine level of 2.0 mg/dL or greater, with a minimum increase of 0.7 mg/dL). The data emerging from the ECLIPSE program suggest that perioperative BP control needs to be tighter than traditionally assumed, since even a 1 mm Hg excursion can be prognostically important, if sustained for 60 minutes or longer. Acute hypertension in nonsurgical patients has not been well studied in the past decade and there are multiple knowledge gaps, including:
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