Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical.

Case StudiesCase Studiesinin

Acute HypertensionAcute Hypertension

Case StudiesCase Studiesinin

Acute HypertensionAcute Hypertension

Edwin G. Avery, MD, CPIEdwin G. Avery, MD, CPIAssistant Professor of AnesthesiologyAssistant Professor of Anesthesiology

Massachusetts General Hospital Heart CenterMassachusetts General Hospital Heart CenterHarvard Medical School Harvard Medical School

Investigations ● Advances ● ApplicationsInvestigations ● Advances ● Applications

Case Studies of Acute HypertensionCase Studies of Acute Hypertension

Case Study #1Case Study #1

Type A Aortic DissectionType A Aortic Dissection

www.radpod.org



AcknowledgementAcknowledgementThank you to Dr. Michael England for Thank you to Dr. Michael England for sharing this interesting casesharing this interesting case

Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection

► HPIHPI: presented to ED complaining of : presented to ED complaining of sudden onset of severe chest pain and sudden onset of severe chest pain and shortness of breath. shortness of breath.

► PHM/PSHPHM/PSH: obesity: obesity

► AllergiesAllergies: NKDA: NKDA

► MedicationsMedications: none: none

► Fam HxFam Hx: noncontributory: noncontributory

► ROSROS: unremarkable: unremarkable

www.edpma.com

44-year-old female presents for surgical correction of a Type A dissection

► GeneralGeneral: anxious, grossly obese. : anxious, grossly obese.

► HtHt: 62 inches : 62 inches WtWt: 102 kg: 102 kg

► VSVS: : 141/45141/45 (R=L)(R=L); HR 80’s ; HR 80’s regreg; Resp 18; ; Resp 18; SpO2 96% SpO2 96% RARA

► NeuroNeuro: alert & oriented x3; no gross : alert & oriented x3; no gross deficitsdeficits

► PulmonaryPulmonary: : B/L ralesB/L rales

► CardiacCardiac: S: S11SS22 reg, reg, grade IV grade IV syst.syst. murmur murmur

► ExtremExtrem: 2+ palpable B/L UE & LE; no : 2+ palpable B/L UE & LE; no edemaedema

turbosquid.com


Chem:Heme:

ECG: no ischemic changes

CT: TEE:

141 112 204.0 24 1.2 < 110 10 250<> 39

12.3LFTs Coags WNL WNL


DiagnosisDiagnosis

Type A Aortic Dissection Type A Aortic Dissection w/severe aortic insufficiencyw/severe aortic insufficiency

ManagementManagement

► Immediate Immediate ββ-blockade-blockade

► Control SBP with IV antihypertensive to prevent aortic Control SBP with IV antihypertensive to prevent aortic rupture & further extension of dissectionrupture & further extension of dissection

► Proceed to the OR for immediate surgical correction Proceed to the OR for immediate surgical correction (ascending aortic replacement, +/- AVR)(ascending aortic replacement, +/- AVR)

www.radiologyassistant.nl


ManagementManagementManagementManagement

► ββ-blockade:-blockade: reduces dP/dt reduces dP/dt

► IV antihypertensive:IV antihypertensive: reduces shear reduces shear forces on the weakened aortic wallforces on the weakened aortic wall

► Surgical correction:Surgical correction: reduces observed reduces observed Type A dissection mortality (~↑2% per Type A dissection mortality (~↑2% per hour). Uncorrected in-hospital hour). Uncorrected in-hospital mortality (58%) vs. surgically mortality (58%) vs. surgically corrected (27.4corrected (27.4%)1.%)1.

www.radiologyassistant.nl

Hagan et al. Jama 2000;283:897


In the ORIn the ORIn the ORIn the OR




CPB

Induction Incision



In the OR – “In the OR – “The ZoneThe Zone””In the OR – “In the OR – “The ZoneThe Zone””

CPB

Induction Incision120

95


In the OR – the drugsIn the OR – the drugsIn the OR – the drugsIn the OR – the drugs

CPB

SNPCLV

SNP sodium nitroprusside

CLV clevidipine

NTG nitroglycerin

Induction Incision

NTG


In the OR – the drugsIn the OR – the drugsIn the OR – the drugsIn the OR – the drugs

CPB

SNPCLV

NTG

SNP sodium nitroprusside

CLV clevidipine

NTG nitroglycerin

Clevidipine dose adjustment (mg/hr)

Induction Incision

10 0 2 4 6 8


SummarySummary

The ultra-short acting dihydropyridine calcium The ultra-short acting dihydropyridine calcium channel blocker, clevidipine, can be used to safely channel blocker, clevidipine, can be used to safely and effectively manage the acute hypertension that and effectively manage the acute hypertension that accompanies one of the most morbid and accompanies one of the most morbid and potentially mortal disorders of the cardiovascular potentially mortal disorders of the cardiovascular system.system.




Acute Coronary SyndromeAcute Coronary Syndrome

http://library.med.utah.edu


AcknowledgementAcknowledgementThank you to Dr. Charles Pollack at the Thank you to Dr. Charles Pollack at the University of Pennsylvania for sharing this University of Pennsylvania for sharing this interesting caseinteresting case


Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome

►58 y/o male presents to ED with 58 y/o male presents to ED with chest pain of acute onsetchest pain of acute onset radiating radiating to left jaw and shoulder, to left jaw and shoulder, accompanied by SOBaccompanied by SOB

►Triage vital signs were pulse Triage vital signs were pulse 92/min, resp 24/min, and 92/min, resp 24/min, and BP BP 212/126 mm Hg212/126 mm Hg

►PMH included known CAD, CHF, PMH included known CAD, CHF, and hyperlipidemiaand hyperlipidemia

►ECG performed in TriageECG performed in Triage

http://mykentuckyheart.com

Acute Anterior STE Myocardial Infarction


► Physical examination: Physical examination: symmetrical symmetrical bounding pulses, diaphoresis, and rales bounding pulses, diaphoresis, and rales in both lung basesin both lung bases

► Management:Management: ASA 325 mgASA 325 mg Clopidogrel 600 mg Clopidogrel 600 mg Unfractionated heparin by IV infusionUnfractionated heparin by IV infusion Nitroglycerin by IV infusionNitroglycerin by IV infusion Beta-blockers are held because of Beta-blockers are held because of

concern over heart failureconcern over heart failure

► Prior to cath lab transfer: recheck BP is Prior to cath lab transfer: recheck BP is 196/118; and patient is diagnosed with196/118; and patient is diagnosed with

www.etopiamedia.net

STEMI + STEMI + Hypertensive EmergencyHypertensive Emergency


Hemodynamic ControlHemodynamic Control

170

160


Cle

vidi

pine

(m

g/hr

)

0

12

64

2

8

10196 192 188176 168 166 162 162


Hemodynamic ControlHemodynamic Control

SummarySummary

Clevidipine can be used safely and effectively to care for Clevidipine can be used safely and effectively to care for a patient with an acute coronary syndrome using a a patient with an acute coronary syndrome using a peripheral IV and a blood pressure cuff. There was no peripheral IV and a blood pressure cuff. There was no evidence of coronary steal or worsening of this patient’s evidence of coronary steal or worsening of this patient’s chest pain. Target BP control was obtained in less than chest pain. Target BP control was obtained in less than 10 minutes.10 minutes.



Aortic Valve ReplacementAortic Valve Replacement


Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement

► HPIHPI: presented with symptoms of : presented with symptoms of shortness of breath and DOE. shortness of breath and DOE.

► PHM/PSHPHM/PSH: AS, MI, CAD (stents x2), HTN : AS, MI, CAD (stents x2), HTN ((brittlebrittle), ), Chol, TIAs secondary to Chol, TIAs secondary to spontaneous cholesterol embolispontaneous cholesterol emboli

► AllergiesAllergies: NKDA: NKDA

► MedicationsMedications: metoprolol: metoprolol

► Fam HxFam Hx: noncontributory: noncontributory

► ROSROS: as per HPI o/w unremarkable: as per HPI o/w unremarkable

78-year-old male presents for aortic valve replacement

► GeneralGeneral: fatigued appearing : fatigued appearing

► HtHt: 72 inches : 72 inches WtWt: 90 kg: 90 kg

► VSVS: 128/62 : 128/62 (R=L)(R=L); HR 60’s ; HR 60’s regreg; Resp 18; ; Resp 18; SpO2 98% SpO2 98% RARA

► NeuroNeuro: alert & oriented x3; no gross : alert & oriented x3; no gross deficitsdeficits

► PulmonaryPulmonary: CTA bilaterally: CTA bilaterally

► CardiacCardiac: S: S11SS22 reg, reg, grade IV grade IV syst.syst. murmur murmur

► ExtremExtrem: 2+ palpable B/L UE & LE; no : 2+ palpable B/L UE & LE; no edemaedema


ChemChem::HemeHeme::

ECGECG: no ischemic changes : no ischemic changes

TEETEE: : Aortic stenosis (AVA 0.7 cmAortic stenosis (AVA 0.7 cm22), ), gradient (P 51/M 32 mmHg w/CI 2.9 gradient (P 51/M 32 mmHg w/CI 2.9 L/min/mL/min/m22))

139 103 254.5 24 1.3 < 91 6.8 172<> 41.2

14.1 LFTs Coags WNL WNL


DiagnosisDiagnosis

Severe Aortic Stenosis with left Severe Aortic Stenosis with left ventricular hypertrophyventricular hypertrophy

ManagementManagement

► Surgical aortic valve replacement with a bioprosthesisSurgical aortic valve replacement with a bioprosthesis

► Control heart rate, maintain NSR, manage SBP with an IV Control heart rate, maintain NSR, manage SBP with an IV antihypertensive to prevent antihypertensive to prevent LV wall stress and LV wall stress and MVOMVO22, ,

avoid hypotensive overshootsavoid hypotensive overshoots






In the OR - In the OR - The ZoneThe ZoneIn the OR - In the OR - The ZoneThe ZoneInduction

CPB

2 4 8 16 2 0 2 4 0

F

F

Clevidipine (mg/hr)

F

- Fentanyl bolus


SummarySummary

Clevidipine can be used safely and effectively to Clevidipine can be used safely and effectively to provide hemodynamic support for patients with provide hemodynamic support for patients with complex cardiovascular disease profiles (i.e. need complex cardiovascular disease profiles (i.e. need to strictly ovoid overshoot hypotension [AS] & to strictly ovoid overshoot hypotension [AS] & reflex tachycardia [AS, LVH, CAD]). Target BP reflex tachycardia [AS, LVH, CAD]). Target BP control was expeditiously obtained and maintained control was expeditiously obtained and maintained in this patient.in this patient.


Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical.

Documents

aortic dissection slide

aortic dissection hpi

aortic rupture

interesting case slide

dissection mortality

observed type

lfts coags wnl wnl case

s reg resp