1
|
Arendash JM, Chiu C, Wang J, Mihm F. Cannabinoid hyperemesis and pheochromocytoma hypertensive urgency: a case report. J Med Case Rep 2024; 18:161. [PMID: 38500192 PMCID: PMC10949556 DOI: 10.1186/s13256-024-04497-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND This report presents a case of cannabinoid-induced hyperemesis syndrome causing repeated violent retching in a patient with a large (8 cm) adrenal pheochromocytoma resulting in hypertensive urgency. CASE PRESENTATION A 69-year-old white male patient with a previously diagnosed pheochromocytoma presented to the emergency department with nausea and vomiting and was found to have hypertensive urgency. Computed tomography scan did not show any acute abdominal pathology and history was inconsistent with a gastrointestinal etiology. Patient had a history of daily cannabinoid use for many years and repeated self-limited hyperemesis episodes, and thus a diagnosis of cannabinoid-induced hyperemesis syndrome was made. It was concluded that the likely explanation for the hypertensive urgency was from physical compression of his adrenal tumor during the episodes of retching resulting in a catecholamine surge. The patient was given antiemetics and admitted to the intensive care unit for blood pressure management. Blood pressure was initially controlled with phentolamine and a clevidipine infusion, then transitioned to oral doxazosin and phenoxybenzamine. Hyperemesis and abdominal pain resolved after 24 hours, and his blood pressure returned to baseline. The patient was discharged with the recommendation to stop all cannabis use. On follow-up, his blood pressure remained well controlled, and he subsequently underwent adrenalectomy for tumor removal. CONCLUSION Hyperemesis can cause hypertensive events in patients with pheochromocytoma by increasing abdominal pressure, leading to catecholamine release.
Collapse
Affiliation(s)
- Jeffrey M Arendash
- Department of Anesthesiology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA.
| | - Cornel Chiu
- Department of Anesthesiology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA
| | - Jocelyn Wang
- Department of Anesthesiology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA
| | - Fred Mihm
- Department of Anesthesiology, Stanford University, 300 Pasteur Dr., Stanford, CA, 94305, USA
| |
Collapse
|
2
|
Kilindimo SS, Abdulkarim A, Simbila AN, Harrison R, Shirima L, Abdallah F, Mukhtar AG, Mfinanga J, Saika J, Kisanga E, Sawe HR. The burden and management strategies of hypertensive crisis in adult patients presenting to emergency departments of district and regional hospitals in Sub-Saharan Africa. Clin Hypertens 2023; 29:27. [PMID: 37777812 PMCID: PMC10544116 DOI: 10.1186/s40885-023-00251-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 09/03/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Hypertensive crisis is among the causes of morbidity and mortality in adult patients with hypertension in Sub-Saharan Africa. We aimed to determine the burden, risk factors and describe the management strategies of hypertensive crisis among adult patients seen at emergency departments of district and regional hospitals in Tanzania. METHODS This was a prospective multicenter longitudinal study which included all 162 district and regional hospitals in Tanzania. It was part of the Tanzania Emergency Care Capacity Survey (TECCS), a large assessment of burden of acute illness and emergency care capacity in Tanzania. Adult patients who presented to emergency departments with blood pressure ≥ 180/110mmHg were enrolled. Demographics, clinical presentation, management, and 24-hours outcomes were recorded using a structured case report form. Descriptive statistics were summarized in frequency and median, while logistic regression was used to evaluate the association between risk factors and presence of hypertensive crisis. RESULTS We screened 2700 patients and enrolled 169 adults, henceforth proportion of adult patients with hypertensive crisis was 63 per 1000. Median age was 62 years (IQR 50-70 years) and predominantly females, 112 (66.3%). Majority 151(89.3%) were self-referred with two-wheel motorcycle being the commonest 46 (27.2%) mode of arrival to the hospital. Hypertensive emergency was found in over half 96 (56.8%) of the patients with hypertensive crisis, with oral medications administered in more than half of them, 71 (74%) as means to control the high blood pressure, and one-third 33 (34.4%) were discharged home. On multivariate analysis increasing age (AOR 4.53, p < 0.001), use of illicit drug (AOR 4.14, p-0.04) and pre-existing hypertension (AOR 8.1, p < 0.001) were independent risk factors for hypertensive crisis occurrence. CONCLUSION Hypertensive crisis among adult patients attending district and regional hospitals is common (63 patients per every 1000 patients). Increasing age, use of illicit drug and pre-existing hypertension are independent associated factors for developing hypertensive crisis.
Collapse
Affiliation(s)
- Said S Kilindimo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania.
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania.
| | - Ahmed Abdulkarim
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Alphonce N Simbila
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Raynald Harrison
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Lucy Shirima
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Farida Abdallah
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Aliasghar G Mukhtar
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Juma Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Joseph Saika
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Emanuel Kisanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| |
Collapse
|
3
|
Davis LL. Hypertensive Emergencies: Implications for Nurses. Nurs Clin North Am 2023; 58:271-281. [PMID: 37536780 DOI: 10.1016/j.cnur.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
An acute elevation of blood pressure (BP) greater than 180/120 mm Hg associated with target organ damage is considered a hypertensive emergency. Patients with a hypertensive emergency need intravenous medications and close monitoring in the intensive care unit. Whereas an acute elevation of BP greater than 180/120 mm Hg without evidence of target organ damage is a hypertensive urgency. Patients with a hypertensive urgency are treated with oral medications and generally discharged home with outpatient follow-up. Patients with either condition need a thorough evaluation to determine cause of the acute increase in BP and education to optimize the treatment regimen long-term.
Collapse
Affiliation(s)
- Leslie L Davis
- University of North Carolina at Chapel Hill, School of Nursing, 4007 Carrington Hall, CB # 7460, Chapel Hill, NC, USA.
| |
Collapse
|
4
|
Benenson I, Waldron FA, Holly C. A Systematic Review and Meta-analysis of the Clinical and Epidemiological Characteristics of Patients with Hypertensive Emergencies: Implication for Risk Stratification. High Blood Press Cardiovasc Prev 2023:10.1007/s40292-023-00586-1. [PMID: 37284909 DOI: 10.1007/s40292-023-00586-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/29/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Acute severe elevation of blood pressure (BP) is a common clinical event, that can present as hypertensive emergency (HTNE) and hypertensive urgency (HTNU). HTNE results in life-threatening target organ damage, including myocardial infarction, pulmonary edema, stroke, and acute kidney injury. It is associated with high utilization of healthcare and increased cost. HTNU is high BP without acute serious complications. AIM The purpose of this review was to examine the clinical-epidemiological characteristics of patients with HTNE and propose a risk stratification framework to differentiate between the two conditions, since prognosis, setting of therapy and treatment is vastly different. METHODS Systematic review. RESULTS Fourteen full-text studies were included in this review. In comparison with HTNU, patients with HTNE had higher mean systolic (mean difference 2.413, 95% CI 0.477, 4.350) and diastolic BP (mean difference 2.043, 95% CI 0.624, 3.461). HTNE were more prevalent in men (OR 1.390, 95% CI 1.207, 1.601), older adults (mean difference 5.282, 95% CI 3.229, 7.335) and those with diabetes (OR 1.723, 95% CI 1.485, 2.000). Non-adherence to BP medications (OR 0.939, 95% CI 0.647, 1.363) and unawareness of hypertension diagnosis (OR 0.807, 95% CI 0.564, 1.154) did not elevate the risk of HTNE. CONCLUSIONS Systolic and diastolic BP are marginally higher in patients with HTNE. Given that these differences are not clinically significant, other epidemiological and medical characteristics (older age, male sex, cardiometabolic comorbidities) as well as patient's presentation should be considered to differentiate between HTNU and HTNE.
Collapse
|
5
|
Liberman AL, Kamel H, Lappin R, Ishak A, Navi BB, Parikh NS, Merkler A, Razzak J. Prevalence of neurological complaints among emergency department patients with severe hypertension. Am J Emerg Med 2023; 64:90-95. [PMID: 36493539 PMCID: PMC9845141 DOI: 10.1016/j.ajem.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Severe hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. METHODS We used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016-2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. RESULTS Based on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5-43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7-6.5%) of all ED visits. Only 2.8% (95% CI: 2.0-3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3-93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. CONCLUSION In a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.
Collapse
Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine.
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Richard Lappin
- Department of Emergency Medicine, Weill Cornell Medicine
| | - Amgad Ishak
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Alexander Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine
| |
Collapse
|
6
|
Xu L, Ba H, Jiang X, Qin Y. Hypertension crisis as the first symptom of renovascular hypertension in children. Ital J Pediatr 2022; 48:191. [PMID: 36461036 PMCID: PMC9717483 DOI: 10.1186/s13052-022-01378-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 11/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Renovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China. METHODS This study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E). RESULTS Fifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases were grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu's arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27). CONCLUSIONS Most RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children's physical examinations is advised.
Collapse
Affiliation(s)
- Lingling Xu
- grid.412615.50000 0004 1803 6239Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Hongjun Ba
- grid.412615.50000 0004 1803 6239Department of Pediatric Cardiovascular, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Xiaoyun Jiang
- grid.412615.50000 0004 1803 6239Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Youzhen Qin
- grid.412615.50000 0004 1803 6239Department of Pediatric Cardiovascular, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| |
Collapse
|
7
|
Abbas H, Hallit S, Kurdi M, Karam R. Non-adherence to antihypertensive medications in Lebanese adults hospitalized for hypertensive urgency and its cost. BMC Cardiovasc Disord 2022; 22:456. [PMID: 36319947 PMCID: PMC9628133 DOI: 10.1186/s12872-022-02907-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/11/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Drug non-adherence is assumed to play an important role in development of hypertensive urgency, which is a common health problem resulting in frequent emergency department admissions and thus increased healthcare spending wastage. The objective of this study is to assess the rate of non-adherence to antihypertensives and to evaluate influencing factors predicting this behavior in Lebanese hypertensive adults. In addition, this study aim to estimate the cost of hospitalization for hypertensive urgency covered by the Ministry of Public Health in patients' non-adherent to their antihypertensives. METHODS A multi-methods approach is used comprising a cross-sectional study, additionally to an observational, retrospective, cost of illness study. A cross-sectional questionnaire based study is conducted from May to Dec, 2019 to address the study objective. Using the Ministry of Public Health hospitalization data during 2019, the cost of hospitalization for hypertensive urgency is assessed. Multivariable analysis is performed to calculate the adjusted odd ratios by fitting a logistic regression model. RESULTS The cross-sectional study includes 494 participants and shows that 43.0% of patients hospitalized and covered by the Ministry of Public Health are non-adherent. The univariate regression model shows that adherence to antihypertensive medications is significantly associated with age (p-value = 0.005) and follow-up visits (p-value = 0.046). The odds of adherence for participants earning more than USD 2000 was 3.27 times that for those who earn less than USD 1000 (p = 0.026). The estimated cost of hospitalization for non-adherent patients is USD 452,353 in 2019. CONCLUSION Non-adherence associated hospitalization costs represents a financial burden to Lebanese health system.
Collapse
Affiliation(s)
- Hanine Abbas
- grid.411324.10000 0001 2324 3572Department of chemistry and Biochemistry, Faculty of Science, Lebanese University, Beirut, Lebanon
| | - Souheil Hallit
- grid.444434.70000 0001 2106 3658School of Medicine and Medical Sciences, Holy Spirit University of Kaslik, P.O Box 446, Jounieh, Lebanon ,grid.512933.f0000 0004 0451 7867Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | - Mazen Kurdi
- grid.411324.10000 0001 2324 3572Department of chemistry and Biochemistry, Faculty of Science, Lebanese University, Beirut, Lebanon
| | - Rita Karam
- grid.411324.10000 0001 2324 3572Department of chemistry and Biochemistry, Faculty of Science, Lebanese University, Beirut, Lebanon ,grid.490673.f0000 0004 6020 2237Quality Assurance of Pharmaceutical Products Department, Lebanese Ministry of Public health, Baabda, Lebanon ,grid.411324.10000 0001 2324 3572Pharmacology Department, Faculty of Medical sciences, Lebanese University, Beirut, Lebanon
| |
Collapse
|
8
|
Weber MA, Schmieder RE, Kandzari DE, Townsend RR, Mahfoud F, Tsioufis K, Kario K, Pocock S, Tatakis F, Ewen S, Choi JW, East C, Lee DP, Ma A, Cohen DL, Wilensky R, Devireddy CM, Lea JP, Schmid A, Fahy M, Böhm M. Hypertension urgencies in the SPYRAL HTN-OFF MED Pivotal trial. Clin Res Cardiol 2022; 111:1269-1275. [PMID: 35852582 PMCID: PMC9622517 DOI: 10.1007/s00392-022-02064-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
The SPYRAL HTN-OFF MED Pivotal trial ( https://clinicaltrials.gov/ct2/show/NCT02439749 ) demonstrated significant reductions in blood pressure (BP) after renal denervation (RDN) compared to sham control in the absence of anti-hypertensive medications. Prior to the 3-month primary endpoint, medications were immediately reinstated for patients who met escape criteria defined as office systolic BP (SBP) ≥ 180 mmHg or other safety concerns. Our objective was to compare the rate of hypertensive urgencies in RDN vs. sham control patients. Patients were enrolled with office SBP ≥ 150 and < 180 mmHg, office diastolic BP (DBP) ≥ 90 mmHg and mean 24 h SBP ≥ 140 and < 170 mmHg. Patients had been required to discontinue any anti-hypertensive medications and were randomized 1:1 to RDN or sham control. In this post-hoc analysis, cumulative incidence curves with Kaplan-Meier estimates of rate of patients meeting escape criteria were generated for RDN and sham control patients. There were 16 RDN (9.6%) and 28 sham control patients (17.0%) who met escape criteria between baseline and 3 months. There was a significantly higher rate of sham control patients meeting escape criteria compared to RDN for all escape patients (p = 0.032), as well as for patients with a hypertensive urgency with office SBP ≥ 180 mmHg (p = 0.046). Rate of escape was similar between RDN and sham control for patients without a measured BP exceeding 180 mmHg (p = 0.32). In the SPYRAL HTN-OFF MED Pivotal trial, RDN patients were less likely to experience hypertensive urgencies that required immediate use of anti-hypertensive medications compared to sham control.
Collapse
Affiliation(s)
- Michael A Weber
- Professor of Medicine, Division of Cardiovascular Medicine, Downstate Medical Center, SUNY Downstate College of Medicine, State University of New York, Brooklyn, NY, USA.
| | | | | | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Felix Mahfoud
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
| | - Konstantinos Tsioufis
- Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kazuomi Kario
- School of Medicine, Jichi Medical University, Tochigi, Japan
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fotis Tatakis
- Hippocratio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sebastian Ewen
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
| | - James W Choi
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - Cara East
- Baylor Research Institute, Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - David P Lee
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Adrian Ma
- Stanford Hospital and Clinics, Stanford, CA, USA
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Wilensky
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Janice P Lea
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Axel Schmid
- University Hospital Erlangen, Erlangen, Germany
| | | | - Michael Böhm
- Klinik Für Innere Medizin III, Universitätsklinikum Des Saarlandes, Saarland University, HomburgSaar, Germany
| |
Collapse
|
9
|
Malik MOHAMMADAZHARUDDIN, Ahmad REHAN, Beg MUJAHID, Ahmad RIZWAN. A comparative study of intravenous labetalol VS intravenous Nitroglycerin in the treatment of hypertensive crises. Indian Heart J 2022; 74:332-334. [PMID: 35667400 PMCID: PMC9453047 DOI: 10.1016/j.ihj.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 11/12/2022] Open
Abstract
Hypertensive crises is still a major public health problem, causing end organ damage like myocardial infarction, stroke, and renal failure. Labetalol and nitroglycerine are among the two most commonly used medicine to control the blood pressure, but there is no head to head comparison between these two medicines. This was a prospective randomized non-blinded study which included 50 patients of hypertensive crises, out which 25 patients received intravenous labetalol and 25 patients received intravenous nitroglycerine. We found that labetalol controlled the blood pressure more rapidly in comparison to nitroglycerine, without causing any extra side effect.
Collapse
|
10
|
Khamsai S, Chootrakool A, Limpawattana P, Chindaprasirt J, Sukeepaisarnjaroen W, Chotmongkol V, Silaruks S, Senthong V, Sittichanbuncha Y, Sawunyavisuth B, Sawanyawisuth K. Hypertensive crisis in patients with obstructive sleep apnea-induced hypertension. BMC Cardiovasc Disord 2021; 21:310. [PMID: 34162333 PMCID: PMC8220687 DOI: 10.1186/s12872-021-02119-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Hypertensive crisis is an urgent/emergency condition. Although obstructive sleep apnea (OSA) in resistant hypertension has been thoroughly examined, information regarding the risk factors and prevalence of hypertensive crisis in co-existing OSA and hypertension is limited. This study thus aimed to determine prevalence of and risk factors for hypertensive crisis in patients with hypertension caused by OSA. Methods The inclusion criteria were age of 18 years or over and diagnosis of co-existing OSA and hypertension. Those patients with other causes of secondary hypertension were excluded. Patients were categorized by occurrence of hypertensive crisis. Factors associated with hypertensive crisis were calculated using multivariate logistic regression analysis. Results There were 121 patients met the study criteria. Of those, 19 patients (15.70%) had history of hypertensive crisis. Those patients in hypertensive crisis group had significant higher systolic and diastolic blood pressure at regular follow-ups than those without hypertensive crisis patients (177 vs. 141 mmHg and 108 vs. 85 mmHg; p value < 0.001 for both factors). After adjusted for age, sex, and Mallampati classification, only systolic blood pressure was independently associated with hypertensive crisis with adjusted odds ratio (95% CI) of 1.046 (1.012, 1.080). Conclusions The prevalence of hypertensive crisis in co-existing OSA and hypertension was 15.70% and high systolic blood pressure or uncontrolled blood pressure associated with hypertensive crisis in patients with OSA-associated hypertension. ![]()
Collapse
Affiliation(s)
- Sittichai Khamsai
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Apichart Chootrakool
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Panita Limpawattana
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Jarin Chindaprasirt
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Wattana Sukeepaisarnjaroen
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Verajit Chotmongkol
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Songkwan Silaruks
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Vichai Senthong
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand
| | - Yuwares Sittichanbuncha
- Department of Emergency Medicine, Mahidol University, Ramathibodi Hospital, Bangkok, Thailand
| | - Bundit Sawunyavisuth
- Department of Marketing, Faculty of Business Administration and Accountancy, Khon Kaen University, Khon Kaen, Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, 123 Mitraparp Road, Khon Kaen, 40002, Thailand.
| |
Collapse
|
11
|
Afonso AM, Sastow D, Cadwell JB, Downey RJ, Fischer GW, Shahrokni A. Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer. J Perioper Pract 2021; 32:301-309. [PMID: 34134558 DOI: 10.1177/17504589211012351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored. METHODS Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission. RESULTS Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission. CONCLUSION Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.
Collapse
Affiliation(s)
- Anoushka M Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dahniel Sastow
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Joshua B Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| |
Collapse
|
12
|
Richard AE, Chomienne MH. Review of Referrals Sent to the Emergency Department for Management of Hypertension. Cardiol Res 2021; 12:156-160. [PMID: 34046109 PMCID: PMC8139747 DOI: 10.14740/cr1233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 11/15/2022] Open
Abstract
Background Hypertensive urgencies, unlike hypertensive emergencies, are severe episodes of hypertension without evidence of end-organ damage. Most recent guidelines advise against referring patients with hypertensive urgencies to the emergency department (ED) for treatment. There is a lack of Canadian data surrounding whether referrals to the ED regarding hypertension are appropriate. We analyzed referrals to the Montfort Hospital ED due to hypertension and assessed if they met the criteria for hypertensive emergencies. Methods This was a retrospective chart study of all ED visits at Montfort Hospital from the 2016 fiscal year with a final diagnosis/chief complaint of hypertension. Charts were assessed to determine if these patients met the criteria for having true hypertensive emergencies. Results Out of the 54,000 visits to the Montfort ED, 254 reported hypertension as a final diagnosis/chief complaint. Of those, 67 patients had been referred by a healthcare practitioner, while 187 were self-referred. None of the referred patients met the criteria for hypertensive emergency; however, eight of these patients did have symptoms indicating a possibility of hypertensive emergency. Six of the self-referred patients met criteria for hypertensive emergency. The majority (71.6%) of patients referred did not require on-site antihypertensive treatment, and 37.3% of patients were sent home with new outpatient prescriptions. Conclusion All the cases referred to the Montfort ED for hypertension were considered hypertensive urgencies and none of them required ED hypertensive treatment. Further investigation is required to help optimize appropriate patient referral to the ED for true hypertensive emergencies and improve management of hypertensive urgencies in the community.
Collapse
Affiliation(s)
- Andre Emmanuel Richard
- Department of Family Medicine, University of Ottawa, 713 Montreal Road, Ottawa, ON H2Z OA2, Canada
| | - Marie-Helene Chomienne
- Department of Family Medicine, University of Ottawa, 713 Montreal Road, Ottawa, ON K1K 0T2, Canda
| |
Collapse
|
13
|
Obied AH, Ahmed AA. Evaluation of the clinical outcome of captopril use for hypertensive urgency in Khartoum State's emergency centres. Afr J Emerg Med 2021; 11:202-206. [PMID: 33680742 PMCID: PMC7910171 DOI: 10.1016/j.afjem.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 11/08/2022] Open
Abstract
Background Captopril is an important drug and is used to control hypertensive urgency world-wide. But there is very little data available regarding the evaluation of its outcomes in hypertensive urgency among African patients. This study aimed to evaluate the clinical outcomes of captopril use for hypertensive urgency at a selection of Sudanese emergency centres. Methods This was a cross-sectional study, conducted between 15 to 30 November 2015. A total of 50 patients, attending a selection of Khartoum State hospital emergency centres, with a clinical diagnosis of hypertensive urgency were approached by investigators for the study. Dose regimen, prognosis, and reduction in systolic and diastolic blood pressure were collected alongside a questionaire to patients regarding their care (compliance, etc.). Data were analysed using the Chi-square Test to compare the mean differences for various results. Differences were considered to be significant at P < 0.05. Results Around two-thirds (60%) of participants were female, and 28% were non-compliant with treatment. A 25mg dose of captopril was the most frequently used dose. Most of the patients (66%) did not have pre-existing disease. The majority of patients showed an improved blood pressure: both systolic and diastolic blood pressures were reduced by 16-25% and 5-15%, respectively. Conclusion The study concluded that the dose of 25 mg of captopril is effective in managing hypertensive urgency and controlling the blood pressure. We also recommend that patients receiving captopril must be observed in the emergency centre for further evaluation.
Collapse
|
14
|
Allgaier J, Emmich M, Rastegar V, Stefan MS, Lagu T. Hypertensive urgency or emergency? The use of intravenous medications in hospitalized hypertensive patients without organ dysfunction. Heart Lung 2020; 49:824-828. [PMID: 33011460 DOI: 10.1016/j.hrtlng.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/07/2020] [Accepted: 09/11/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current guidelines poorly define hypertensive urgency and recommend Oral (PO) medications over intravenous (IV). OBJECTIVE To describe hospital management of hypertensive urgency and compare characteristics and outcomes of PO vs. IV medications. METHODS We used descriptive statistics and created generalized linear models to evaluate within-subject blood pressure (BP) changes over 24 hours. RESULTS 179 patients had an average age of 62 and 58% female. Chronic hypertension was common (165, 88%), as was chronic renal disease (40.6%). IV medications were common (146, 81.6%) and associated with higher comorbidity burden, prior kidney disease, and longer length of stay (2.5, 1.6-3.8 vs. 1.4, 0.9-2.2, p=0.007). 66 (35.3%) developed and 43 (23.5%) new organ dysfunction, but outcomes were similar between groups. BP was similar between groups after 12 hours. CONCLUSIONS IV medication use was common and decreased BP more rapidly. Outcomes including BP were similar to PO administration, except for length of stay.
Collapse
Affiliation(s)
- Joshua Allgaier
- Department of Medicine, University of Massachussets Medical School-Baystate, Springfield, MA, United States.
| | - Megan Emmich
- Department of Medicine, University of Massachussets Medical School-Baystate, Springfield, MA, United States
| | - Vida Rastegar
- Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, United States
| | - Mihaela S Stefan
- Department of Medicine, University of Massachussets Medical School-Baystate, Springfield, MA, United States; Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, United States
| | - Tara Lagu
- Department of Medicine, University of Massachussets Medical School-Baystate, Springfield, MA, United States; Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, United States
| |
Collapse
|
15
|
Strauss M, Leischik R, Jehn U, Padberg JS, Pistulli R, Kümpers P, Reinecke H. [The hypertensive emergency situation : Recommendations for initial drug therapy management]. Med Klin Intensivmed Notfmed 2020; 117:41-48. [PMID: 32940723 DOI: 10.1007/s00063-020-00728-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The hypertensive emergency situation is characterized by an acute-mostly life-threatening-blood pressure derailment with the risk of acute end organ damage. It is an acute manifestation of arterial hypertension, which manifests in a variety of symptoms. The etiology is in most cases long-term (chronic) hypertension as a result of low compliance or inadequate antihypertensive therapy. It can also occur as a first manifestation of arterial hypertension. It requires timely antihypertensive drug therapy, which should be initiated in an intensive or intermediate care unit. The choice of antihypertensive therapy regimen should be based on the underlying end organ damage. Fast-acting, easily controllable and intravenously administered substances should be preferred. The most commonly used substances (groups) are urapidil, nitroglycerin, beta blockers and short-acting calcium channel blockers. With a few exceptions, a deliberate, rapid reduction in blood pressure of no more than 20-25% of the initial value is sufficient for extracerebral causes. A subsequent systolic blood pressure target of 160/100 mm Hg should be aimed for within the next 2-6 h. An overly rapid drop in blood pressure can lead to reduced blood flow to the central nervous system due to changes in autoregulation. Exceptions to this rule are acute aortic dissection and flash pulmonary edema-in these cases, prompt blood pressure normalization should be achieved. The initial acute therapy should be followed by a more detailed investigation of the cause and a long-term therapy setting based on this.
Collapse
Affiliation(s)
- M Strauss
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland. .,Klinik für Kardiologie, Lehrbereich Prävention und Gesundheitsförderung, Fakultät für Gesundheit, Universität Witten/Herdecke, Hagen, Deutschland.
| | - R Leischik
- Klinik für Kardiologie, Lehrbereich Prävention und Gesundheitsförderung, Fakultät für Gesundheit, Universität Witten/Herdecke, Hagen, Deutschland
| | - U Jehn
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - J-S Padberg
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - R Pistulli
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - P Kümpers
- Medizinische Klinik D, Allgemeine Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - H Reinecke
- Klinik für Kardiologie I: Koronare Herzerkrankung, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| |
Collapse
|
16
|
Stanistreet B, Nicholas JA, Bisognano JD. An Evidence-Based Review of Elevated Blood Pressure for the Inpatient. Am J Med 2020; 133:165-169. [PMID: 31705851 DOI: 10.1016/j.amjmed.2019.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
Elevated blood pressure is common in patients who are hospitalized. There are no guidelines and few recommendations to help inpatient providers manage patients with elevated blood pressure. There are no normal reported values for blood pressure in the inpatient and recording circumstances often widely vary. Many factors may influence blood pressure such as pain, anxiety, malaise, nicotine withdrawal, or withholding home medications. This review of available literature suggests potential harm and little to no potential benefit in treating asymptomatic patients with elevated blood pressure. This review also found no evidence that asymptomatic elevated blood pressure progresses to lead to end-organ damage. However, there are clear instances of hypertensive emergency where treatment is indicated. Conscientious adjustment of an anti-hypertensive regimen should be undertaken during episode of elevated blood pressure associated with end-organ damage.
Collapse
Affiliation(s)
- Bryan Stanistreet
- Department of Internal Medicine, Division of Geriatrics, University of Rochester Medical Center, Rochester, NY.
| | - Joseph A Nicholas
- Department of Internal Medicine, Division of Geriatrics, University of Rochester Medical Center, Rochester, NY
| | - John D Bisognano
- Department of Internal Medicine, Division of Cardiology, University of Rochester Medical Center, Rochester, NY
| |
Collapse
|
17
|
Abstract
Hypertensive crisis is a relatively rare condition in children. However, if not treated, it might be life-threatening and lead to irreversible damage of vital organs. Clinical presentation of patients with hypertensive crisis can vary from very mild (hypertensive urgency) to severe symptoms (hypertensive emergency) despite similarly high blood pressure (BP). Individualized assessment of patients presenting with high BP with emphasis on the evaluation of end-organ damage rather than on the specific BP number is a key in guiding physician's initial management of a hypertensive crisis. The main aim of the treatment of hypertensive crisis is the prevention or treatment of life-threatening complications of hypertension-induced organ dysfunction, including neurologic, ophthalmologic, renal, and cardiac complications. While the treatment strategy must be directed toward the immediate reduction of BP to reduce the hypertensive damage to these organs, it should not be at a too fast rate to cause hypoperfusion of vital organs by an excessively rapid reduction of BP. Thus, intravenous continuous infusions rather than intravenous boluses of antihypertensive medications should be the preferable mode of initial treatment of children with hypertensive emergency.
Collapse
Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Biomedical Center, 2nd Faculty of Medicine and Faculty of Medicine in Pilsen, Charles University in Prague, V Uvalu 84, 15006, Prague 5, Czech Republic. .,Motol University Hospital, V Uvalu 84, 15006, Prague 5, Czech Republic.
| | - Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
18
|
Abstract
Approximately 33% of adults in the United States have high blood pressure; approximately 1% will present with a hypertensive emergency. Hypertension emergency is typically defined as a blood pressure great than 180/120 mmHg leading to end organ damage. However, it is important to note that an acute rise in blood pressure may also lead to end organ damage before achieving the blood pressure threshold. Therapeutic intervention should be a short-acting, easily titratable, intravenous antihypertensive medication based on the type of end-organ damage, pharmacokinetics, and comorbidities. This review focuses on presentations and treatment of hypertensive emergency.
Collapse
|
19
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
|
20
|
Shao PJ, Sawe HR, Murray BL, Mfinanga JA, Mwafongo V, Runyon MS. Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania. BMC Cardiovasc Disord 2018; 18:158. [PMID: 30068315 PMCID: PMC6090910 DOI: 10.1186/s12872-018-0895-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania. METHODS This was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency. RESULTS We screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45-67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively. CONCLUSION In our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.
Collapse
Affiliation(s)
- Patrick J. Shao
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Hendry R. Sawe
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Brittany L. Murray
- Division of Paediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA USA
| | - Juma A. Mfinanga
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Victor Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Michael S. Runyon
- Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina USA
| |
Collapse
|
21
|
Brody AM, Miller J, Polevoy R, Nakhle A, Levy PD. Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department. Curr Hypertens Rep 2018; 20:30. [PMID: 29637311 DOI: 10.1007/s11906-018-0831-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Hypertension (HTN) is the most prevalent cardiovascular disease and poses a major population level risk to long-term health outcomes. Despite this critical importance, and the widespread availability of effective and affordable medications, blood pressure (BP) remains uncontrolled in up to 50% of the diagnosed patients. This problem is exacerbated in communities with limited access to primary care, who often utilize hospital emergency departments (EDs) as their primary healthcare resource. Despite the ubiquity of patients presenting to EDs with severely elevated BP, a unified, evidence-based approach is not yet widely implemented, and both under- and overtreatment are common. The purpose of this review is to describe an approach towards institutional policy regarding asymptomatic HTN, in which we will translate the accepted principles of appropriate outpatient BP management to ED and inpatient settings. RECENT FINDINGS Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN. Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.
Collapse
Affiliation(s)
- Aaron M Brody
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave., Detroit, MI, 48202, USA.
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Rimma Polevoy
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Asaad Nakhle
- Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, 48202, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave., Detroit, MI, 48202, USA
| |
Collapse
|
22
|
Abstract
PURPOSE OF REVIEW Early lowering of blood pressure is advised for patients with severe hypertension associated with signs of impending or progressive organ damage, whereas aggressive treatment is not recommended in patients with asymptomatic severe hypertension. As treatment goals for asymptomatic hypertension and true hypertensive emergency drastically differ, it is essential to identify patients with evidence of impending or progressive organ damage. Biomarkers may assist providers in identifying high-risk patients who would benefit from early blood pressure reduction. RECENT FINDINGS In this review, we discuss both currently available and investigational biomarkers that may help identify patients who might benefit from more aggressive therapy. We focus on serum and urinary biomarkers associated with acute cardiovascular, renal, and cerebrovascular damage. There is a dearth of literature regarding the use of biomarkers to assess acute hypertension-related target organ damage. We are primarily forced to draw conclusions on the use of biomarkers from studies of related conditions such as acute heart failure. Further research is needed on the clinical significance of abnormal levels of novel biomarkers of renal, cardiac, and cerebral dysfunction in the setting of severe hypertension, particularly in those patients without overt clinical signs of organ failure.
Collapse
Affiliation(s)
- Stephen Boone
- Departments of Emergency Medicine and Internal Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX, 77030, USA.
| | - Dick Kuo
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX, 77030, USA
| |
Collapse
|
23
|
Maweni RM, Sunderland N, Rahim Z, Odih E, Kallampallil J, Saunders T, Akunuri S. Clinical characteristics of Black patients with hypertensive urgency. Ir J Med Sci 2018; 187:1089-96. [PMID: 29541933 DOI: 10.1007/s11845-018-1787-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypertensive urgency is defined as a severely elevated systolic blood pressure (SBP) of ≥ 180 mmHg and/or diastolic blood pressure (DBP) of ≥ 120 mmHg, in the absence of end organ damage. It is known that there are racial differences in prevalence and severity of hypertension but there is a dearth of studies looking at hypertensive urgency in Black populations living in Europe. AIMS We sought to define the clinical characteristics of Black patients presenting with hypertensive urgency, in order to better define the risks and complications this growing population of patients faces. METHODS This was a single-centre retrospective cohort study of 63 consecutive Black and Afro-Caribbean patients attending a South London district general hospital outpatient hypertension clinic from April 2014 to June 2016. All patients had initially presented with hypertensive urgency to their GP, the Emergency Department, or the hospital's medical take. RESULTS The cohort had a mean age of 52.7 years and an even gender balance. Thirty-four patients had a pre-existing diagnosis of hypertension, with a 9-year median time since diagnosis. This was the first presentation of hypertension for the remaining 46%. Other comorbidities found were diabetes mellitus (10%), ischaemic heart disease (5%), hyperlipidaemia (5%), and cerebrovascular disease (2%). Patients who drank alcohol regularly were found to have significantly higher blood pressures than those who did not. Most patients presented with typical symptoms of uncontrolled hypertension, with headache (25%) and chest pain (16%) being most common. Features of end organ damage were also common, with 32 patients having hypertensive retinopathy, 16 patients having proteinuria and 14 patients found to have left ventricular hypertrophy on echocardiography. CONCLUSION The large proportion of newly diagnosed hypertensive patients presenting with end organ signs of prolonged uncontrolled hypertension suggests that there are significant numbers of undiagnosed Black patients in the community, suggesting that we should more actively conduct test for hypertension and its complications when we encounter these patients, who constitute a growing part of the populations in Europe.
Collapse
|
24
|
Abstract
A rapid and severe increase in blood pressure resulting in new or progressive end-organ damage is defined as hypertensive emergency. Clinicians should effectively use the patient interview, physical examination, and additional testing to differentiate hypertensive emergency from nonemergent hypertension. Patients with evidence or high suspicion for end-organ damage should be expediently referred from the outpatient setting to a higher level of care. Knowledge of appropriate hypertensive emergency management and the ability to initiate this care in the clinic could help reduce patient morbidity in certain situations. Patients presenting with nonemergent hypertension can continue to be safely managed in the clinic.
Collapse
Affiliation(s)
- Manish Suneja
- Division of Nephrology and Hypertension, Department of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - M Lee Sanders
- Division of Nephrology and Hypertension, Department of Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
| |
Collapse
|
25
|
Yang WC, Lin MJ, Chen CY, Wu HP. Clinical overview of hypertensive crisis in children. World J Clin Cases 2015; 3:510-3. [PMID: 26090371 PMCID: PMC4468897 DOI: 10.12998/wjcc.v3.i6.510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 02/15/2015] [Accepted: 03/16/2015] [Indexed: 02/05/2023] Open
Abstract
Hypertensive emergencies and hypertensive urgencies in children are uncommonly encountered in the pediatric emergency department and intensive care units, but the diseases are potentially a life-threatening medical emergency. In comparison with adults, hypertension in children is mostly asymptomatic and most have no history of hypertension. Additionally, measuring accurate blood pressure values in younger children is not easy. This article reviews current concepts in pediatric patients with severe hypertension.
Collapse
|
26
|
SHI J, WANG X, YING Y, XU L, Zhu D. Hypertensive urgency after administration of a single low dose of mirtazapine-a case report. Iran J Public Health 2015; 44:282-4. [PMID: 25905065 PMCID: PMC4401889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/21/2014] [Indexed: 11/04/2022]
Abstract
Mirtazapine is a new antidepressant that can increase noradrenergic and serotonergic neurotransmission. It is also a postsynaptic antagonist of 5-HT2 and 5-HT3. In addition, it has only a weak affinity for 5-HT1 receptors and has very weak muscarinic anticholinergic and histamine (H1) antagonist properties. We report a case of hypertensive urgency that ensued after a patient took a single low dose of mirtazapine.
Collapse
Affiliation(s)
- Jiana SHI
- Dept. of Pharmacy, Tongde Hospital of Zhejiang Province, Hangzhou, China,Dept. of Pharmacology, Toxicology and Biochemical Pharmaceutics, Zhejiang University, Hangzhou, China
| | - Xiaojun WANG
- Dept. of Pharmacy, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Yin YING
- Dept. of Pharmacy, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Lin XU
- Dept. of Cardiovascular Medicine, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Danyan Zhu
- Dept. of Pharmacology, Toxicology and Biochemical Pharmaceutics, Zhejiang University, Hangzhou, China,Corresponding Author:
| |
Collapse
|