Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology...
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Transcript of Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology...
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
Case Studies of Acute HypertensionCase Studies of Acute Hypertension
Case Study #1Case Study #1
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
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
Chem:Heme:
ECG: no ischemic changes
CT: TEE:
141 112 204.0 24 1.2 < 110 10 250<> 39
12.3LFTs Coags WNL WNL
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
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
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
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
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
In the ORIn the ORIn the ORIn the OR
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
In the ORIn the ORIn the ORIn the OR
CPB
Induction Incision
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
In the ORIn the ORIn the ORIn the OR
In the OR – “In the OR – “The ZoneThe Zone””In the OR – “In the OR – “The ZoneThe Zone””
CPB
Induction Incision120
95
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
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
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
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
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
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.
Case Study 1: Type A Aortic DissectionCase Study 1: Type A Aortic Dissection
Case Studies of Acute HypertensionCase Studies of Acute Hypertension
Case Study #2Case Study #2
Acute Coronary SyndromeAcute Coronary Syndrome
http://library.med.utah.edu
Case Study #2Case Study #2
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 Studies of Acute HypertensionCase Studies of Acute Hypertension
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
Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome
► 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
Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome
Hemodynamic ControlHemodynamic Control
170
160
Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome
Cle
vidi
pine
(m
g/hr
)
0
12
64
2
8
10196 192 188176 168 166 162 162
Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome
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.
Case Study #2: Acute Coronary SyndromeCase Study #2: Acute Coronary Syndrome
Case Study #3Case Study #3
Aortic Valve ReplacementAortic Valve Replacement
Case Studies of Acute HypertensionCase Studies of Acute Hypertension
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
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
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
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
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
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
In the ORIn the ORIn the ORIn the OR
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
In the ORIn the ORIn the ORIn the OR
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
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
Case Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement
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 Study 3: Aortic Valve ReplacementCase Study 3: Aortic Valve Replacement