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Vascular Dysfunction: Sequelae of Acute Hypertension

Vascular Dysfunction: Sequelae of Acute Hypertension. Overview. Introduction: Scope of the problem Effects of acute BP elevation on the vessel wall Traditional parenteral antihypertensive treatment Pharmacokinetic profiles and key clinical studies Guidelines for use

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Vascular Dysfunction: Sequelae of Acute Hypertension

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  1. Vascular Dysfunction: Sequelae of AcuteHypertension

  2. Overview • Introduction: Scope of the problem • Effects of acute BP elevation on the vessel wall • Traditional parenteral antihypertensive treatment • Pharmacokinetic profiles and key clinical studies • Guidelines for use • Clinical trial update: New paradigm in management of acute hypertension

  3. Acute and chronic hypertension: Clinical context Chronic hypertension Acute vascular reactivity Hypertensive emergencies Courtesy of S Aronson, MD.

  4. Sympathetic overactivation drives acute hypertension Arteriosclerosis Chronic hypertension Sympathetic overactivation Acute hypertension Important triggers include clonidine withdrawal, cocaine abuse, certain surgical settings 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.

  5. Components of blood pressure: New focus on pulse pressure PRESSURE HR x SV = CO BP*/ CO = SVR CO x MAP = work MAP = 1/3 PP + DBP All in the absence of pulsations FLOW Courtesy of S Aronson, MD.

  6. Perioperative ISH associated with postoperative adverse events N = 2069 scheduled for CABG ISH = isolated systolic hypertension Aronson S et al. Anesth Analg. 2002;94:1079-84.

  7. Proposed risk index for renal dysfunction/failure post-CABG: Importance of pulse pressure N = 4801 scheduled for bypass Multicenter Study of Perioperative Ischemia (McSPI) Aronson S et al. Circulation. 2007;115:733-42.

  8. Acute hypertension: Subgroups and settings Acute hypertension Hypertensive urgency Hypertensive emergency Perioperative hypertension Operating roomPostanesthesia care Emergencydepartment Intensive care unit

  9. JNC 7 definitions Chobanian AV et al. Hypertension. 2003;42:1206-52.

  10. Cardiopulmonary ADHF ACS Acute pulmonary edema Acute aortic syndromes Neurovascular Hypertensive encephalopathy Stroke Ocular Papilloedema Renal Acute renal dysfunction Hypertensive urgencies/emergencies: Patients and organ systems at risk 1% of hypertensives (1990 data). Contemporary prevalence may be lower ACS = acute coronary syndromeADHF = acute decompensated heart failure Calhoun DA, Oparil S. N Engl J Med. 1990;323:1177-83.Marik PE, Varon J. Chest. 2007;131:1949-62.

  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.

  12. Urgencies Headache (22%) Epistaxis (17%) Faintness and psychomotor agitation (10%) Emergencies Chest pain (27%) Dyspnea (22%) Neurological deficit (21%) Hypertensive urgencies/emergencies: Most common presenting symptoms Zampaglione B et al. Hypertension. 1996;27:144-7.

  13. 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 • Cardiac • Carotid • Peripheral vascular • Abdominal aortic • Intraperitoneal/intrathoracic • Pheochromocytoma tumor 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. Perioperative antihypertensive therapy is common in cardiac surgery N = 1660 patients, (N = 191 anesthesiologists) Mean MAP threshold for treatment (mm Hg) 106.0 86.3 97.1 109.0 Vuylsteke A et al. J Cardiothorac Vasc Anesth. 2000;14:269-73.

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