Recognition of systolic hypertension for hypertension

Prolonged Duration of Blood Pressure Drops During General Anesthesia Is Associated With Worse Outcomes After Mechanical Thrombectomy

Background and Purpose: Optimal periprocedural management of blood pressure during mechanical thrombectomy (MT) remains controversial. This study aimed to investigate the relationship between the duration of blood pressure drops during general anesthesia and the outcomes in large vessel occlusion (LVO) patients treated with MT.

Methods: We retrospectively reviewed our prospectively collected data for LVO patients treated with MT between January 2018 and July 2020. Intraprocedural mean arterial pressure (MAP) was recorded every 5 min throughout the procedure. Baseline MAP minus each MAP value recorded during general anesthesia was defined ΔMAP. Cumulated time (in min) and longest continuous episode (in min) with ΔMAP more than 10, 15, 20, 25, and 30 mmHg were calculated, respectively. Poor outcome was defined as 90-day modified Rankin score (mRS) 3–6. Associations between cumulated time of different ΔMAP thresholds and poor outcome were determined using binary logistic regression models.

Results: A total of 131 patients were finally included in the study. After controlling for age, atrial fibrillation, baseline NIHSS, baseline ASPECTS, procedure duration of MT, and times of retrieval attempts, the results indicated that cumulated time of MAP drop more than 10 mmHg (OR 1.013; 95% CI 1.004–1.023; P = 0.007) and 15 mmHg (OR 1.011; 95% CI 1.002–1.020; P = 0.017) were independently associated with poor outcomes.

Conclusion: Prolonged episodes of intraprocedural MAP lowering were more likely to have poor outcomes in LVO patients following MT with general anesthesia, which might be helpful in guiding intraprocedural hemodynamic management of patients under general anesthesia.

Mean arterial pressure and systolic blood pressure for detection of hypotension during hemapheresis: implications for patients with baseline hypertension

Mean arterial pressure (MAP) has been characterized as a more sensitive and physiologically appropriate hemodynamic parameter in the detection of hemapheresis-related hypotension, resulting in a much closer correlation with the presence of symptomatic hypotension. Patients were enrolled over a 12-month period and data collected on any previous diagnosis of hypertension, antihypertensive therapy used, indication for apheresis, age decile, and gender. Baseline vital signs, any hypotensive signs or symptoms observed, and the patient's vital signs at the time of any hypotensive episode were recorded. Patients were assigned to a subgroup, sensitivity and specificity analysis performed, positive likelihood ratios calculated, receiver operating characteristic curves constructed, and ideal cutoff values identified. The incidence of hypotension among our study population was found to be 6.8%. Over all procedures, systolic blood pressure (SBP) was determined to be a "poor" test for detecting hypotension, while MAP demonstrated a "fair" capacity. A downward normalization was evident in the ideal cutoff value based upon a patient's hypertensive history. The currently accepted SBP less than 80 mmHg cutoff failed to detect hypotensive episodes among baseline hypertensive patients, raising questions about its sensitivity. Based upon physiologic principles and study findings, a MAP-based criterion is preferable in the diagnosis of hypotension during hemapheresis.

Mean arterial pressure (MAP): an alternative and preferable measurement to systolic blood pressure (SBP) in patients for hypotension detection during hemapheresis

Current protocols utilize systolic blood pressure (SBP) of less than 80 mmHg as objective evidence of hypotension during hemapheresis. However, tissue hypoperfusion is the pathophysiologic endpoint of low blood pressure, and mean arterial pressure (MAP), rather than SBP, is the physiologic driving force behind blood flow to organs and tissues. It is thus hypothesized that MAP is more appropriate than SBP in the assessment of hypotension and that a threshold MAP can be utilized as a sensitive indicator of hypotension during hemapheresis. Thirty-one patients who experienced hypotension during hemapheresis over a 4.5 year period reflecting forty-four hypotensive episodes were selected. The initial phase of each hemapheresis procedure provided baseline MAP and blood pressure (BP) measurements as control values. BP and MAP were then determined at the onset of subjective hypotension and compared to one another by using regression and sensitivity analyses. Correlation coefficients between SBP and MAP were found to be 0.8097 in baseline normotensive patients and 0.7725 in hypotensive patients. Sensitivity in the detection of hypotension was 0.09% for SBP equal to 80 mmHg and 56.81% for MAP equal to 70 mmHg. An SBP of 80 mmHg or less was therefore concluded to be a less sensitive and physiologically less appropriate measurement of hypotension than MAP. As a single value less than 70 mmHg or a series of successive measurements trending downward toward 70 mmHg, MAP provides an objective assessment of hypotension that may precede hemodynamic decompensation.

Benefits of treating hypertension in the elderly: should age affect treatment decisions?

Do the benefits of treating hypertension extend equally to all age groups, particularly the very elderly? Several large controlled trials have been published in recent years that confirm the benefits of the treatment of hypertension in terms of morbidity and mortality. However, these trials included only relatively small numbers of patients aged > or = 80 years. Data regarding such patients have been extracted and subjected to meta-analysis, but with inconclusive results. Further difficulties arise as a result of the range of therapeutic agents employed. Therefore, uncertainty still surrounds the value of treating very elderly patients with hypertension. The J-curve hypothesis, i.e. that a blood pressure threshold exists below which there is an increase in the rate of cardiac events, has been a concern in treating elderly patients. Upon close examination, this appears to be spurious. The Hypertension in the Very Elderly Trial study sets out to provide conclusive evidence for the benefits or otherwise of treating hypertension in the very elderly and has just commenced. The results of this trial will not be available for some time. In the meantime, should physicians initiate or continue treatment for very elderly individuals with hypertension? If so, what regimens should be employed and should target blood pressure levels be set? At the present time, it would appear sensible to provide treatment for very elderly patients with hypertension, particularly those with evidence of complications or target organ damage. In relatively healthy individuals with mild-to-moderate hypertension, the guiding principle should be 'the lower the blood pressure the better'. Regarding the choice of therapeutic agent, a low-dose diuretic remains the first choice therapy.

Effects of nonsteroidal anti-inflammatory drug therapy on blood pressure and peripheral edema

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used drugs with potential effects on systemic blood pressure. NSAIDs act by inhibiting synthesis of prostaglandins (PGs) from arachidonic acid via cyclooxygenase (COX)-1 and COX-2, the 2 isoforms of COX. NSAIDs may affect blood pressure via the renin-angiotensin pathway, alterations in sodium and water retention in the kidneys, inhibition of vasodilating PGs, and production of various vasoconstricting factors, including endothelin-1 and P450-mediated metabolites of arachidonic acid. In 2 meta-analyses, it was found that NSAIDs have small but significant effects on blood pressure, most notably in hypertensive patients on antihypertensive medication. NSAIDs cause small (<5 mm Hg) elevations in systolic blood pressure, and little or no change in diastolic blood pressure. The incidence rates of hypertension and peripheral edema were low, ranging from <1% to >9% of patients. The incidence and levels of hypertension associated with COX-2 inhibitors are within the range of those observed with nonspecific NSAIDs. Apparent differences between the COX-2 inhibitors celecoxib and rofecoxib may be functions of differences in study population susceptibilities to NSAID-mediated hypertensive effects. Patients at risk for hypertension should be monitored for changes in blood pressure during NSAID treatment.

Differences in knowledge, attitude and behavior with respect to hypertension among cardiologists, neurologists and other physicians in internal medicine

It is known that the knowledge, attitude and behavior (KAB) of physicians with respect to hypertension directly affect the prevention of hypertension and associated cardiovascular diseases. To investigate the differences in KAB among cardiologists, neurologists and other physicians, 1,722 potential participants were selected by stratified random sampling. Among these, 1,609 participants took part in the present survey, and 948 of this group were eligible for the present analysis. The data were collected using a self-administrated questionnaire. Results showed that, with respect to knowledge and attitude regarding hypertension, 15.3% of cardiologists, 15.2% of neurologists and 7.2% of other internals selected the correct answers to all questions (p<0.05). The criteria of hypertension were not correctly understood by about two-thirds of physicians, including both cardiologists and neurologists. With regard to behavior, 16.5% of cardiologists, 17.9% of neurologists and 9.6% of other internals selected the correct answers to all questions (p<0.05). A majority of physicians considered that routine blood pressure measurements were not necessary in cases uncomplicated by cardiovascular disease and other disease, such as nephrotic disease, or diabetes mellitus. One-half to two-thirds of physicians did not believe that life style modifications reduce blood pressure. For each question, cardiologists showed the highest, and other internals the lowest, percentage of correct responses to all items in the questionnaire. These findings indicate that cardiovascular health education must be strengthened for all physicians, and not only for specialists.