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Differences in Diagnosis and Management of Hypertensive Urgencies and Emergencies According to Italian Doctors from Different Departments Who Deal With Acute Increase in Blood Pressure-Data from Gear (Gestione Dell'emergenza e Urgenza in ARea Critica) Study. J Clin Med 2022; 11:jcm11112986. [PMID: 35683380 PMCID: PMC9181679 DOI: 10.3390/jcm11112986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/23/2022] [Accepted: 05/23/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Diagnosis and treatment of hypertension emergency (HE) and urgency (HU) may vary according to the physicians involved and the setting of the treatment. The aim of this study was to investigate differences in management of HE and HU according to the work setting of the physicians. Methods: The young investigators of the Italian Society of Hypertension developed a 23-item questionnaire spread by email invitation to the members of Italian Scientific societies involved in the field of emergency medicine and hypertension. Results: Six-hundred and sixty-five questionnaires were collected. No differences emerged for the correct definitions of HE and HU or for the investigation of possible drugs that may be responsible for an acute increase in BP. The techniques used to assess BP values (p < 0.004) and the sizes of cuffs available were different according to the setting. Cardiologists more frequently defined epistaxis (55.2% p = 0.012) and conjunctival hemorrhages (70.7%, p < 0.0001) as possible presentation of HE, and rarely considered dyspnea (67.2% p = 0.014) or chest pain (72.4%, p = 0.001). Intensive care (IC) unit doctors were more familiar with lung ultrasound (50% p = 0.004). With regard to therapy, cardiologists reported the lowest prescription of i.v. labetalol (39.6%, p = 0.003) and the highest of s.l. nifedipine (43.1% p < 0.001). After discharge, almost all categories of physicians required home BP assessment or referral to a general practitioner, whereas hypertensive center evaluation or ambulatory BP monitoring were less frequently suggested. Conclusion: Management and treatment of HE and HU may be different according to the doctor’s specialty. Educational initiatives should be done to standardize treatment protocols and to improve medical knowledge.
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Hsu CY, Huang LY, Saver JL, Wu YL, Lee JD, Chen PC, Lee M, Ovbiagele B. Oral short-acting antihypertensive medications and the occurrence of stroke: a nationwide case-crossover study. Hypertens Res 2019; 42:1794-1800. [PMID: 31300722 DOI: 10.1038/s41440-019-0300-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 05/19/2019] [Accepted: 06/06/2019] [Indexed: 12/16/2022]
Abstract
The purpose of the study was to clarify whether short-acting antihypertensives are associated with the occurrence of ischemic stroke and intracerebral hemorrhage (ICH). This was a retrospective case-crossover study using the Taiwan National Health Insurance Research Database. We identified all adult patients hospitalized with a primary diagnosis of ischemic stroke or ICH between January 2005 and December 2013. For each case, short-term and long-term exposure to short-acting antihypertensives, including nifedipine, labetalol and captopril, during the case vs. control periods were compared, and odd ratios (ORs) and 95% confidence intervals (CIs) for ischemic stroke or ICH were calculated with adjustment for confounders. Among 272785 ischemic stroke and 77798 ICH patients, the mean age was 77.8 ± 14.3 years and 70.8 ± 16.6 years, respectively. The short-term use of the three short-acting antihypertensives were all associated with an increase in the incidence of ischemic stroke (nifedipine: OR 4.51, 95% CIs 3.99-5.11; labetalol: OR 2.07; 95% CIs 1.71-2.51; captopril: OR 1.98, 95% CIs 1.72-2.29) and ICH (nifedipine: OR 2.98, 95% CIs 2.30-3.84; labetalol: OR 2.37; 95% CIs 1.66-3.39; captopril: OR 2.48; 95% CIs 1.69-3.63). The long-term use of short-acting nifedipine for 30 days was associated with a modest increase in the risk for ischemic stroke (OR 1.86; 95% CIs 1.42-2.45). Overall, the short-term use of short-acting antihypertensives is associated with a modest increase in the incidence of stroke, and short-acting nifedipine is linked to a substantial rise in the incidence of ischemic stroke. The long-term use of short-acting nifedipine was also related to an increased incidence of ischemic stroke. Physicians should be cautious of prescribing these short-acting antihypertensives.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ling-Ya Huang
- School of Pharmacy, National Taiwan University, Chiayi, Taiwan
| | - Jeffrey L Saver
- Stroke Center and Department of Neurology, Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yi-Ling Wu
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Pei-Chun Chen
- Department of Public Health, China Medical University, Taoyuan, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.
| | - Bruce Ovbiagele
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, USA
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Khan MS, Roberts MS. Challenges and innovations of drug delivery in older age. Adv Drug Deliv Rev 2018; 135:3-38. [PMID: 30217519 DOI: 10.1016/j.addr.2018.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 08/31/2018] [Accepted: 09/07/2018] [Indexed: 12/12/2022]
Abstract
Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.
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Gillman PK. A reassessment of the safety profile of monoamine oxidase inhibitors: elucidating tired old tyramine myths. J Neural Transm (Vienna) 2018; 125:1707-1717. [PMID: 30255284 DOI: 10.1007/s00702-018-1932-y] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/17/2018] [Indexed: 01/24/2023]
Abstract
This review appraises over 150 recent original papers reporting data that demonstrate the greatly reduced tyramine content of modern-day 'foods', about which the medical literature has a paucity of information. It discusses the cardiovascular pharmacology of tyramine and the characteristics, extent, risks, and treatment of the blood pressure increases that sometimes result from tyramine ingestion (the pressor response). In past decades, cheese was the only food associated with documented fatalities resulting from hypertension. Today, few foods contain problematically high tyramine levels, which is a result of changes in international food production techniques (especially the use of starter cultures), and hygiene regulations. Nowadays, even 'matured' cheeses are usually safe in healthy-sized portions. The mechanism by which tyramine may be produced in foods (by certain micro-organisms) is explained and hundreds of recent estimations of cheeses are reviewed. Numerous other previously inadequately documented foods are reviewed, including fish and soy sauces, salami-type sausages, dried meats, beers, wines, and various condiments. Evidence that the risk of harm from the pressor response has previously been overstated is reviewed, and the iatrogenic harms from hasty and aggressive treatment of hypertensive urgency are re-evaluated. Evidence now suggests that MAOIs are of comparable safety to many newer drugs and are straightforward to use. Previously held concerns about MAOIs are misplaced and some are of over-estimated consequence. The variability of pressor sensitivity to tyramine between individuals means that the knowledge and judgement of doctors, and some care, are still required.
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Chou CL, Chou CY, Hsu CC, Chou YC, Chen TJ, Chou LF. Old habits die hard: a nationwide utilization study of short-acting nifedipine in Taiwan. PLoS One 2014; 9:e91858. [PMID: 24637880 PMCID: PMC3956761 DOI: 10.1371/journal.pone.0091858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 02/16/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To investigate the nationwide trend of ambulatory prescriptions of short-acting nifedipine on a PRN (pro re nata) order over a fifteen-year period in Taiwan. METHODS The systematic sampling claims datasets (0.2% sampling ratio) of ambulatory care visits within Taiwan's National Health Insurance from 1997 to 2011 were analyzed. The prescriptions of short-acting capsule-form nifedipine on a PRN order were stratified by the patient's age, the prescribing physician's specialty, and the setting of healthcare facility for each year. RESULTS During the study period, 8,189,681 visits were analyzed. While the utilization rate of calcium channel blockers changed with time from 2.8% (13,767/489,636) in 1997 to 5.1% (31,349/614,719) in 2011, that of short-acting nifedipine were from 1.0% (n = 5,070) to 0.2% (n = 1,246). However, short-acting capsule-form nifedipine on a PRN order still existed (from 447 prescriptions in 1997 to 784 in 2011). More than one half of these PRN nifedipines were prescribed by the internists and to the elderly patients; almost four-fifths of PRN nifedipines were prescribed during non-emergent consultations. CONCLUSION The physicians in Taiwan still had the habit of prescribing short-acting nifedipines for PRN use. The reason for such practices and the impact on patients' health deserve attention.
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Affiliation(s)
- Chia-Lin Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Yu Chou
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department and Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
- College of Pharmacy, Taipei Medical University, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Medicine, Tzu Chi University, Hualian, Taiwan
| | - Chia-Chen Hsu
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yueh-Ching Chou
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department and Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Institute of Hospital and Health Care Administration, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Fang Chou
- Department of Public Finance, National Chengchi University, Taipei, Taiwan
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Weder AB, Erickson S. Treatment of Hypertension in the Inpatient Setting: Use of Intravenous Labetalol and Hydralazine. J Clin Hypertens (Greenwich) 2010; 12:29-33. [DOI: 10.1111/j.1751-7176.2009.00196.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jones SA, Lancaster MK. Calcium-channel blockers and cardiac arrhythmias within the elderly population. Future Cardiol 2008; 4:207-9. [PMID: 19804324 DOI: 10.2217/14796678.4.3.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Burton TJ, Wilkinson IB. The dangers of immediate-release nifedipine in the emergency treatment of hypertension. J Hum Hypertens 2008; 22:301-2. [PMID: 18239624 DOI: 10.1038/sj.jhh.1002324] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Zwadlo C, Borlak J. Nifedipine represses ion channels, transporters and Ca2+-binding proteins in hearts of spontaneously hypertensive rats. Toxicol Appl Pharmacol 2006; 213:224-34. [PMID: 16343576 DOI: 10.1016/j.taap.2005.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Revised: 10/07/2005] [Accepted: 10/31/2005] [Indexed: 10/25/2022]
Abstract
The Ca(2+) antagonists nifedipine has been used for more than three decades to treat hypertension, but its effects on the transcriptional regulation of cardiac genes are basically unknown. We therefore studied expression of genes coding for ion channels, ion transporters and associated partners as well as Ca(2+)-binding proteins in ventricular tissue of normotensive and spontaneously hypertensive (SH) rats after repeated intraperitoneally (i.p.) dosing of nifedipine. Notably, we observed significant (P < 0.05) repression in transcript levels of most of the genes investigated, including cardiac Na(+), K(+), Ca(2+)-channels (L-type Ca(2+)-channel, K(ir)3.4, K(ir)6.1, Na(v)1.5), ATP-driven ion exchangers (Na(+)-K(+)-ATPase, NCX-1, PMCA 2 and 4, SERCA 2a and 2b) and their associated partners (phospholamban, RyR-2) as well as cytoskeletal proteins (alpha and beta-MHC, alpha cardiac and alpha skeletal actin, troponin T and I). Repression in transcript levels was, however, only seen in ventricular tissue of hypertensive animals. This points to fundamental differences in the mode of action of nifedipine in diseased and healthy animals. Indeed, this preponderance of repressed genes will promote disturbed ion homeostasis to result in contractile dysfunction. It is of considerable importance that repressed gene expression was also seen in end-stage human heart failure. We propose repression of cardiac-specific gene expression as a hallmark of nifedipine treatment in hypertrophic hearts.
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Affiliation(s)
- Carolin Zwadlo
- Fraunhofer Institute of Toxicology and Experimental Medicine, Drug Research and Clinical Inhalation, Nicolai-Fuchs-Str. 1, D-30625 Hannover, Germany
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Montes Santiago J, Inaraja Bobo M, del Campo Fernández V. Nifedipino oral o sublingual: utilidad y efectividad a largo plazo de la educación médica para disminuir su uso en la hipertensión. Rev Clin Esp 2003. [DOI: 10.1016/s0014-2565(03)71185-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fischberg GM, Lozano E, Rajamani K, Ameriso S, Fisher MJ. Stroke precipitated by moderate blood pressure reduction. J Emerg Med 2000; 19:339-46. [PMID: 11074327 DOI: 10.1016/s0736-4679(00)00267-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Rapid lowering of blood pressure can precipitate or worsen ischemic strokes. This usually has been observed in the setting of profoundly lowered pressure and hypotension. We report on six patients in whom ischemic neurologic injury ensued or worsened after moderate reduction of blood pressure by pharmacological treatment. The 6 patients suffered new or worsened ischemic neurologic deficits after receiving oral or intravenous antihypertensive medications, mostly after relatively small doses. Mean arterial blood pressure in these patients was decreased by 25 +/- 7.7%, or 37 +/- 16 mm Hg (mean +/- SD) without resultant hypotension. These cases emphasize the potential hazards of moderate blood pressure reduction by antihypertensive medications in the setting of an acute ischemic stroke or transient ischemic attack (TIA), as well as rapidly treated hypertension even in those who have not yet manifested ischemic symptoms.
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Affiliation(s)
- G M Fischberg
- University of Southern California, Los Angeles, California, USA
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