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124 © Postgraduate Medicine, Volume 126, Issue 4, August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
C L I N I C A L F E AT U R E S
The Management of Acute Hypertension in Patients With Renal Dysfunction: Labetalol or Nicardipine?
Joseph Varon, MD1,2
Karina M. Soto-Ruiz, MD3
Brigitte M. Baumann, MD4
Pierre Borczuk, MD5
Chad M. Cannon, MD6
Abhinav Chandra, MD7
David Martin Cline, MD8
Deborah B. Diercks, MD9
Brian Hiestand, MD8
Amy Hsu, MS10
Preeti Jois-Bilowich, MD11
Brian Kaminski, DO12
Phillip Levy, MD13
Richard M. Nowak, MD14
Jon W. Schrock, MD15
W. Frank Peacock, MD16
1Department of Emergency Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX; 2Dorrington Medical Associates, Galveston, TX; 3Pediatric Emergency Medicine Department, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX; 4Department of Emergency Medicine, Cooper University Hospital, Camden, NJ; 5Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; 6Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, KS; 7Department of Emergency Medicine, Kaiser Permanente, Sacramento, CA; 8Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; 9Department of Emergency Medicine, University of California, Davis Medical Center, Davis, CA; 10Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, OH; 11Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL; 12Department of Emergency Medicine, Toledo Hospital, Toledo, OH; 13Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI; 14Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; 15Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH; 16Department of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Houston, TX
Correspondence: Joseph Varon, MD, FACP, FCCP, FCCM,2219 Dorrington Street,Houston, Texas 77030.Tel: 713-669-1670Fax: 713-669-1671E-mail: [email protected]
DOI: 10.3810/pgm.2014.07.2790
Abstract
Study Objectives:�7R�FRPSDUH�WKH�VDIHW\�DQG�HI¿FDF\�RI�86�)RRG�DQG�'UXJ�$GPLQLVWUDWLRQ��)'$��UHFRPPHQGHG� GRVHV� RI� ODEHWDORO� DQG� QLFDUGLSLQH� IRU� K\SHUWHQVLRQ� �+71��PDQDJH�PHQW�LQ�D�VXEVHW�RI�SDWLHQWV�ZLWK�UHQDO�G\VIXQFWLRQ��5'���Design:�5DQGRPL]HG��RSHQ�ODEHO��PXOWLFHQWHU�SURVSHFWLYH�FOLQLFDO�WULDO��Setting:�7KLUWHHQ�8QLWHG�6WDWHV�WHUWLDU\�FDUH�HPHUJHQF\�GHSDUWPHQWV��Patients or Participants:�6XEJURXS�DQDO\VLV�RI�WKH�(YDOXDWLRQ�RI�,9�&DUGHQH��1LFDUGLSLQH�� DQG�/DEHWDORO�8VH� LQ� WKH�(PHUJHQF\�'HSDUWPHQW� �&/8(�� FOLQLFDO� WULDO��7KH�VXEMHFWV�ZHUH�����SDWLHQWV�ZLWK�5'��LH��FUHDWLQLQH�FOHDUDQFH�!����P/�PLQ��ZKR�SUHVHQWHG�WR�WKH�HPHUJHQF\�GHSDUWPHQW�ZLWK�D�V\VWROLF�EORRG�SUHVVXUH��6%3��"�����PP+J�RQ���FRQVHFX�WLYH�UHDGLQJV�DQG�IRU�ZKRP�WKH�HPHUJHQF\�SK\VLFLDQ�IHOW�LQWUDYHQRXV�DQWLK\SHUWHQVLYH�WKHUDS\�ZDV�GHVLUDEOH���Interventions:�7KH�)'$�UHFRPPHQGHG�GRVHV�RI�HLWKHU�ODEHWDORO�RU�QLFDUGLSLQH�IRU�+71�PDQDJHPHQW�� �Measurements:�7KH�QXPEHU�RI�SDWLHQWV� DFKLHYLQJ� WKH�SK\VLFLDQ¶V�SUHGH¿QHG� WDUJHW�6%3�UDQJH�ZLWKLQ����PLQXWHV�RI� WUHDWPHQW��Results:�3DWLHQWV� WUHDWHG�ZLWK�QLFDUGLSLQH�ZHUH�ZLWKLQ�WDUJHW�UDQJH�PRUH�RIWHQ�WKDQ�WKRVH�UHFHLYLQJ�ODEHWDORO������YV������ P =���������2Q���6%3�PHDVXUHV��SDWLHQWV�WUHDWHG�ZLWK�QLFDUGLSLQH�ZHUH�PRUH�OLNHO\�WR�DFKLHYH�WKH�WDUJHW�UDQJH�RQ�HLWKHU���RU�DOO���UHDGLQJV�WKDQ�ZHUH�SDWLHQWV�WUHDWHG�ZLWK�ODEHWDORO������YV������P =���������/DEHWDORO�SDWLHQWV�ZHUH�PRUH�OLNHO\�WR�UHTXLUH�UHVFXH�PHGLFDWLRQ������YV������P =���������$GYHUVH�HYHQWV�WKRXJKW�WR�EH�UHODWHG�WR�HLWKHU�WUHDWPHQW�JURXS�ZHUH�QRW�UHSRUWHG�LQ�WKH����PLQXWH�DFWLYH�VWXG\�SHULRG��DQG�SDWLHQWV�KDG�VORZHU�KHDUW�UDWHV�DW�DOO�WLPH�SRLQWV�DIWHU���PLQXWHV��P !��������Conclusions:�,Q�VHYHUH�+71�ZLWK�5'��QLFDUGLSLQH�WUHDWHG�SDWLHQWV�DUH�PRUH�OLNHO\�WR�UHDFK�D�WDUJHW�EORRG�SUHVVXUH�UDQJH�ZLWKLQ����PLQXWHV�WKDQ�DUH�SDWLHQWV�UHFHLYLQJ�ODEHWDORO��Clinical Implications:�:LWKLQ����PLQXWHV�RI�DGPLQLVWUDWLRQ��QLFDUGLSLQH�LV�PRUH�HI¿FDFLRXV�WKDQ�ODEHWDORO�IRU�DFXWH�EORRG�SUHVVXUH�FRQWURO�LQ�SDWLHQWV�ZLWK�5'�
Keywords:�DFXWH�GLVHDVH��DQWLK\SHUWHQVLYH�DJHQWV�WKHUDSHXWLF�XVH��K\SHUWHQVLRQ�GUXJ�WKHUDS\��NLGQH\�GLVHDVHV�GUXJ�WKHUDS\
Introduction
+\SHUWHQVLRQ��+71��LV�D�VLJQL¿FDQW�ZRUOGZLGH�FDXVH�RI�PRUELGLW\�DQG�PRUWDOLW\�����,W�LV�HVWLPDWHG�E\�WKH�:RUOG�+HDOWK�2UJDQL]DWLRQ�WKDW���ELOOLRQ�SHRSOH�ZLOO�VXIIHU�IURP�WKLV�FRQGLWLRQ�LQ�WKH�QH[W����\HDUV���0DQ\�RI�WKHVH�SDWLHQWV����±����ZLOO�SUHVHQW�WR�WKH�HPHUJHQF\�GHSDUWPHQW��('��ZLWK�VHYHUHO\�HOHYDWHG�EORRG�SUHVVXUH��%3��DW�VRPH�SRLQW�LQ�WKHLU�OLIHWLPH���$OWKRXJK�WKHUH�LV�QR�IRUPDO�VWDQGDUG�RI�FDUH�IRU�PDQDJHPHQW�RI�SURIRXQGO\�HOHYDWHG�%3�LQ�WKH�('�5�PRVW�FOLQLFLDQV�DJUHH�WKDW�K\SHUWHQVLYH�HPHUJHQFLHV��LH��WKRVH�FLUFXPVWDQFHV�ZKHUH�VHYHUHO\�HOHYDWHG�%3�LV�DVVRFLDWHG�ZLWK�DFXWH�HQG�RUJDQ�GDPDJH��UHTXLUH�LPPHGLDWH��FRQWUROOHG�%3�UHGXFWLRQ�DQG�FORVH�PRQLWRULQJ�����:LWKRXW�DSSURSULDWH�PDQDJHPHQW��WKH���\HDU�PRUWDOLW\�RI�K\SHUWHQVLYH�HPHUJHQFLHV�LV�DV�KLJK�
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Management of Acute HTN in Patients With Renal Dysfunction
© Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 125
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected] : No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Methods and Materials
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Page 3
Varon et al
126 © Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
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Results
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Table 1. Demographics, Past Medical History, and Initial Blood Pressure and Laboratory Values
Parameter Total Randomization Arm
Nicardipine Labetalol P Value
Total number of subjects 104 52 52Age (years): mean ± standard deviation 57.4 ± 16.68 56.8 ± 17.83 58.0 ± 15.61 0.73Female, n/N (%) 57/104 (54.81) 35/52 (67.31) 22/52 (42.31) 0.10Race
Caucasian, n/N (%) 22/103 (21.36) 13/52 (25.00) 9/51 (17.65) 0.36Black, n/N (%) 81/103 (78.64) 39/52 (75.00) 42/51 (82.35)Hispanic or Latino, n/N (%) 5/104 (4.8) 3/52 (5.8) 2/52 (3.8) 0.99Hx of smoking, n/N (%) 56/104 (53.8) 20/52 (38.5) 36/52 (69.2) 0.002 Current smoker, n/N (%) 35/104 (33.7) 12/52 (23.1) 23/52 (44.2) 0.02Hx of stimulant use, n/N (%) 19/104 (18.3) 7/52 (13.5) 12/52 (23.1) 0.21 Cocaine 14/19 (73.7) 4/7 (57.1) 10/12 (83.3) 0.31 Amphetamine 3/19 (15.8) 2/7 (28.6) 1/12 (8.3) 0.52 Current stimulant use 5/104 (4.8) 3/52 (5.8) 2/52 (3.8) 0.99BMI (kg/m2) median 26.8 26.1 27.1 0.58 Q1,Q3 (22.3, 30.7) (21.7, 30.8) (23.5, 30.5)First SBP (mm Hg), mean ± SD 218.7 ± 22.4 219.8 ± 23.5 217.6 ± 21.4 0.64
First DBP (mm Hg), mean ± SD 115.8 ± 19.4 113.4 ± 19.2 118.3 ± 19.4 0.16Heart rate (bpm) median 84.0 83.5 86.5 0.86 Q1,Q3 (69.0, 98.5) (70.0, 97.5) (68.0, 99.5)Past medical history
Hx of hypertension 101/104 (97.1) 51/52 (98.1) 50/52 (96.2) 0.99Hx of previous admission for hypertensive crisis 43/95 (45.3) 23/48 (47.9) 20/47 (42.6) 0.60+[�RI�FKURQLF�UHQDO�LQVXIÀFLHQF\ 24/103 (23.3) 12/52 (23.1) 12/51 (23.5) 0.96Hx of ESRD on dialysis 28/103 (27.2) 16/52 (30.8) 12/51 (23.5) 0.41Hx of diabetes mellitus 40/104 (38.5) 25/52 (48.1) 15/52 (28.9) 0.04Initial laboratory data
BUN (mg/dL) median 25.5 27.0 22.5 0.39 Q1,Q3 (15.0, 36.5) (15.5, 36.5) (14.0, 36.5) Creatinine (mg/dL) median 2.3 2.7 2.0 0.58 Q1,Q3 (1.2, 6.0) (1.1, 7.1) (1.3, 4.3) BNP N 21 10 11 0.99 Median (pg/dL) 382.0 481.5 382.0 Q1,Q3 (143.0, 2258) (143.0, 3375) (141.0, 2258)
Abbreviations: BMI, body mass index; BNP, B-type natriuretic peptide; BUN, blood urea nitrogen; DBP, diastolic blood pressure; ESRD, end stage renal disease; Hx, history; Q1,Q3, interquartile range; SBP, systolic blood pressure.
Page 4
Management of Acute HTN in Patients With Renal Dysfunction
© Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 127
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)RXU�YDULDEOHV��7DEOH����ZHUH�LQFOXGHG�LQ�WKH�¿QDO�PXO�WLYDULDEOH�ORJLVWLF�UHJUHVVLRQ�PRGHO��:H�DGMXVWHG�VLWHV�LQ�WKH�PRGHO�EHFDXVH�UDQGRPL]DWLRQ�ZDV�VWUDWL¿HG�E\�VLWHV��6WUDWL¿FD�WLRQ�ZDV�SHUIRUPHG�SRVW�KRF��DV�WKH�VWDJH�RI�WKH�SDWLHQWV¶�UHQDO�GLVHDVH�FRXOG�QRW�EH�DVFHUWDLQHG�DW�WKH�WLPH�RI�HQUROOPHQW��2QO\�WKH�DEVHQFH�RI�D�SULRU�KLVWRU\�RI�VWURNH�DQG�IHPDOH�VH[�ZHUH�VLJQL¿FDQWO\� DVVRFLDWHG�ZLWK� UHDFKLQJ� WKH� WDUJHW�KHDUW� UDWH��5DQGRPL]DWLRQ�WR�QLFDUGLSLQH�RU�ODEHWDORO�ZDV�QRW�VLJQL¿FDQWO\�DVVRFLDWHG�ZLWK�UHDFKLQJ�WKH�WDUJHW�KHDUW�UDWH��ZKLFK�ZDV�WKH�SULPDU\�RXWFRPH��LH��PHW�WDUJHW�6%3�ZLWKLQ����PLQXWHV��
Discussion
,Q�WKLV�VXEDQDO\VLV�RI�WKH�&/8(�VWXG\��SDWLHQWV�ZLWK�EDVHOLQH�5'�ZKR�UHFHLYHG�QLFDUGLSLQH�ZHUH�PRUH�OLNHO\�WR�DFKLHYH�WKHLU�WDUJHW�%3�ZLWKLQ����PLQXWHV��%ORRG�SUHVVXUH�UHVSRQVH�FXUYHV� IRU� QLFDUGLSLQH� DQG� ODEHWDORO� VHSDUDWHG� ZLWKLQ���� �PLQXWHV� RI� WUHDWPHQW�� DQG� QLFDUGLSLQH�WUHDWHG� SDWLHQWV�ZHUH�OHVV�OLNHO\�WR�UHTXLUH�UHVFXH�WKHUDS\�LQ�WKH�SRVWWUHDWPHQW�SHULRG��$OWKRXJK�WKHVH�¿QGLQJV�ZHUH�JHQHUDOO\�ZLWKLQ� WKH�
Table 2. Signs and Symptoms at Presentation
Parameter Total Randomization Arm
Nicardipine Labetalol
Total number of subjects 104 52 52Shortness of breath, n (%) 32 (30.77%) 17 (32.69%) 15 (28.85%)Chest pain, n (%) 27 (25.96%) 17 (32.69%) 10 (19.23%)Syncope/dizziness, n (%) 24 (23.08%) 9 (17.31%) 15 (28.85%)Blurred vision/diplopia, n (%) 16 (15.38%) 9 (17.31%) 7 (13.46%)Epigastric discomfort, n (%) 14 (13.46%) 7 (13.46%) 7 (13.46%)Confusion, n (%) 4 (3.85%) 2 (3.85%) 2 (3.85%)Diminished level of consciousness, n (%)
4 (3.85%) 1 (1.92%) 3 (5.77%)
Hematuria, n (%) 2 (1.92%) 2 (3.85%) 0 (0.00%)Tachycardia,a n (%) 16 (15.4%) 12 (23%) 4 (7.7%)Headache, n (%) 43 (41.35%) 19 (36.54%) 24 (46.15%)Nausea, n (%) 31 (29.81%) 15 (28.85%) 16 (30.77%)Weakness, n (%) 27 (25.96%) 13 (25.00%) 14 (26.92%)
aP = 0.030. No statistical differences for all other comparisons between nicardipine and labetalol.
Page 5
Varon et al
128 © Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Warning: No duplication rights exist for this journal. Only JTE Multimedia, LLC holds rights to this publication. Please contact the publisher directly with any queries.
Figure 1. Change in SBP within 30 minutes from randomization.
Abbreviation: SBP, systolic blood pressure.
Table 3. Target Range Achievement and Rescue Medication Use
Parameter Total Randomization Arm P Value
Nicardipine Labetalol
Total number of subjects 104 52 52Met target SBP within 30 minutes 88/103 (85.4%) 48/52 (92.3%) 40/51 (78.4%) 0.046Number of instances within SBP target range = 5 or 6 37/104 (35.6%) 24/52 (46.2%) 13/52 (25.0%) 0.024Any rescue medication 23/104 (22.1%) 9/52 (17.3%) 14/52 (26.9%) 0.237
Abbreviation: SBP, systolic blood pressure.
Figure 2. +HDUW�UDWH�SURÀOH�ZLWKLQ����PLQXWHV�IURP�UDQGRPL]DWLRQ�
Page 6
Management of Acute HTN in Patients With Renal Dysfunction
© Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260 129
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Conclusion
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Acknowledgments
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Table 4. Final Multivariable Logistic Model for Patients With Creatinine Clearance # 75a
Variable Odds Ratio (95% CI) P Value
Site 0.98 (0.93, 1.04) 0.87Nicardipine vs labetalol 1.996 (0.50, 8.05) 0.33No history of stroke 49.507 (4.05, 605.82) 0.002Female 13.135 (1.55, 111.07) 0.0181
aOutcome: met SBP target range within 30 minutes.
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Varon et al
130 © Postgraduate Medicine, Volume 126, Issue 4, July/August 2014, ISSN – 0032-5481, e-ISSN – 1941-9260ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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