PATIENTS' SAFETY AND FEASIBILITY OF INTRAVENOUS URAPIDIL IN THE PRETREATMENT OF PHEOCHROMOCYTOMA PATIENTS IN A NORMAL WARD SETTING - AN ANALYSIS OF 20 CONSECUTIVE CASES

Short-acting urapidil compared to long-acting phenoxybenzamine in the management of pheochromocytoma

PURPOSE

In patients with pheochromocytoma current guidelines recommend preoperative alpha-adrenoceptor blockade with selective or nonselective antagonists for at least 7-14 days. To date, no information exists about orally administered urapidil retard, a short-acting selective antagonist.

METHODS

The medical records of consecutive patients with pheochromocytoma between 2010 and 2023 were reviewed. Patients received phenoxybenzamine between 2010 and 2017, intravenous urapidil was given between 2017 and 2019. Orally administered urapidil retard has been used from 2019 until present.

RESULTS

Forty-nine patients with pheochromocytomas were included. Twenty-six patients received orally administered long-acting phenoxybenzamine and 23 patients were pretreated with short-acting intravenous (n = 8) or orally administered urapidil (n = 15). Treatment prior to surgery was significantly shorter with intravenously (3 days (IQR, 3-4), p = 0.015) or orally administered urapidil (2 days (IQR 2-3), p = 0.003) compared to phenoxybenzamine (7 days (IQR, 4-10)). Side effects were more often in the phenoxybenzamine group (17/26 vs 6/23, p = 0.02). The modified hemodynamic instability (HI) score was low and there was no significant difference between patients treated with phenoxybenzamine and those treated with intravenous or oral urapidil (29 (IQR 18.5-38); 26 (IQR 18-42); 31 (IQR 15-36) ns). No 30-day postoperative mortality or cardiovascular complications occurred in any of the three groups. The postoperative hospital stay was significantly shorter in the orally administered urapidil group compared to the phenoxybenzamine group (3 days (IQR 3-5)) vs 4 days (IQR 4-5)), p = 0.04).

CONCLUSION

Oral pretreatment with urapidil retard is well tolerated for patients with pheochromocytoma, enabling a safe intra- and postoperative course.

Modern Management of Hypertensive Emergencies

Acute increases of blood pressure values are common causes of patients' presentation to emergency departments, and their management represents a clinical challenge. They are usually described as 'hypertensive crises', 'hypertensive urgencies', terms that should be abandoned because they are misleading and inappropriate according to a recent task force of the European Society of Cardiology, which recommended to focus only on 'hypertensive emergencies'. The latter can be esasily identified by using the Brain, Arteries, Retina, Kidney, and/or Heart (BARKH) strategy as herein described. Although current guidelines recommendations/suggestions for treatment of these patients are not evidence-based, owing to the lack of randomized clinical trials, improved understanding of the underlying pathophysiology has changed the approach to management of the patients presenting with hypertensive emergencies in recent years. Starting from these premises and a systematic review of the available studies graded by their quality, using the AHA class of recommendation/level of evidence grading, whenever possible, we herein present a novel a streamlined symptoms- and evidence-based algorithm for the assessment and management of patients with hypertensive emergencies.