Hypertensive Emergencies Publications (901)
Hypertensive Emergencies Publications
PRES frequently develops in the context of cytotoxic medication, (pre)eclampsia, sepsis, renal disease or autoimmune disorders. The treatment is symptomatic and is determined by the underlying condition. The overall prognosis is favorable, since clinical symptoms as well as imaging lesions are reversible in most patients. However, neurological sequelae including long-term epilepsy may persist in individual cases.
Women were included in this analysis if they were HIV-uninfected and had singleton gestations and at least one prenatal blood pressure measurement.
We measured stillbirth, preterm birth, small for gestational age, and neonatal death in women with and without hypertension in pregnancy.
We included 14,170 pregnancies. Hypertension occurred in 3156 (22.2%) women, with 602 (19.1%) defined as severe. Severe hypertension increased risk of stillbirth (RR 4.4; 95% CI 3.2-6.2), preterm birth (RR 2.5; 95% CI 2.2-2.8), small for gestational age (RR 2.7; 95% CI 2.3-3.1) and neonatal death (RR 5.1; 95% CI 2.9-5.6). Non-severe hypertension increased risk of stillbirth (RR 2.0; 95% CI 1.5-2.7), preterm birth (RR 1.2; 95% CI 1.1-1.3), and small for gestational age (RR 1.6; 95% CI 1.4-1.8). Perinatal outcomes were worse in women with hypertension who had spontaneous preterm birth compared to those who underwent iatrogenic preterm delivery.
Hypertension in pregnancy is common in Botswana and leads to a large number of adverse outcomes. Improved management of hypertension in pregnancy may improve perinatal morbidity and mortality.
An ED visit was considered to be a hypertensive emergency if it met all the following criteria: diagnosis of acute hypertension, at least 1 diagnosis indicating acute target organ damage, and qualifying disposition (admission to the hospital, death, or transfer to another facility). The incidence of adult ED visits for acute hypertension increased monotonically in the period from 2006 through 2013, from 170 340 (1820 per million adult ED visits overall) to 496 894 (4610 per million). Hypertensive emergency was rare overall, accounting for 63 406 visits (677 per million adult ED visits overall) in 2006 to 176 769 visits (1670 per million) in 2013. Among adult ED visits that had any diagnosis of hypertension, hypertensive emergency accounted for 3309 per million in 2006 and 6178 per million in 2013.
The estimated number of visits for hypertensive emergency and the rate per million adult ED visits has more than doubled from 2006 to 2013. However, hypertensive emergencies are rare overall, occurring in about 2 in 1000 adult ED visits overall, and 6 in 1000 adult ED visits carrying any diagnosis of hypertension in 2013. This figure is far lower than what has been sometimes cited in previous literature.
Temperature data were matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the temperature and the frequency of individual cardiovascular emergencies. In addition, three threshold-temperatures (0°C, 10°C, 20°C) were defined in order to determine the frequency of cardiovascular emergencies above and below each cut-off value. The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system.
A total of 35,390 cardiovascular emergencies were treated by Emergency Physicians. Transient Loss of Consciousness increased at high temperatures (above 20°C): +43% (95%-CI: [27%; 59%]). In contrast, Coronary Artery Disease +26% (95%-CI: [17%; 34%]), Cardiac Pulmonary Edema +21% (95%-CI: [14%; 27%]), Hypertensive Urgency +18% (95%-CI: [10%; 25%]) and Cerebrovascular Accident +17% (95%-CI: [8%; 24%]) increased at low temperatures, particularly below 10°C (significance level for all: p<0.001). No temperature-related effect was seen in Cardiac Arrhythmia and Pulmonary Embolism and no significant correlation was found between the severity of emergencies and temperature.
Our findings suggest that some cardiovascular emergencies such as Coronary Artery Disease, Cardiac Pulmonary Edema, Hypertensive Urgency and Cerebrovascular Accident are more frequent in low temperatures even under mild climatic conditions.
Each is presented in a unique way, although some patients with hypertensive emergency report non-specific symptoms. Treatment includes multiple medications for quick and effective action with security to reduce blood pressure, protect the function of organs remaining, relieve symptoms, minimize the risk of complications and improve patient outcomes.
A phone follow-up patients was organized.
During this period, 170 patients were identified: 95 (56%) hypertensive crisis and 75 (44%) hypertensive emergencies: 25 OAP (33%), 18 ischemic stroke (24%), 15 hemorrhagic stroke (20%), 9 angina (12%) and 8 different. The clinical characteristics of hypertensive emergencies are preferentially dyspnea (27%) motor deficit (36%), and chest pain (16%). The BP of hypertensive emergencies at their admission (3 measurements, oscillometric automatic device) is close to the hypertensive crisis (198.17±19.3 to 96.4±21.2mmHg versus 191±31.6 to 96.12±21). The BP controlled after 15minutes of rest is lower for crisis compared to real emergencies (152±47 to 79±28 vs. 174±31 to 86±26). Age emergency is larger (77±14 vs. 67±17), the number of slightly larger drug (1.79 versus 1.67±1±1). Telephone follow-up was performed after an average period of three months. Ninety-nine patients were contacted by telephone: 46 patients who were admitted for hypertensive emergency patients and 53 for a push. Eighteen deaths have been recorded, including 15 among hypertensive emergencies (9 in hemorrhagic stroke, 5 for ischemic stroke, and 1 for OAP) with 5-hospital deaths within 48hours after admission and 10 within 3 months in patients hospitalized with hypertensive emergency or 33%. Seventy-seven patients out of 99 had been reviewed by their attending physicians. A questionnaire was sent by mail to patients who have not answered the phone contacts, and responses are pending.
Hypertensive emergencies hospitalized in Timone Hospital represent 44% of patients hospitalized for emergency HTA. Their gravity is 1/3 since most patients die within three months warranting closer management of these fragile patients by creating a specialized consulting postemergency.
Case details were collected and data analysed for the perioperative management of 29 patients who underwent laparoscopic removal of PCC and PGL. Parameters collected included details of preoperative alpha-and beta blockade, tumour size, number of hypertensive surges, dose of sodium nitroprusside (SNP) and other vasodilators used and incidence of postoperative hypotension and other complications.
All patients received prazosin for pre-operative optimization. Hypertensive emergencies were seen in 4 patients during induction and endotracheal intubation and in 1 patient during pneumoperitoneum insufflation. Overall mean number of hypertensive emergencies was 3.41 (SD-2.45). The patients undergoing PGL removal had significantly more crisis compared to those undergoing unilateral PCC removal. The dose of SNP used correlated significantly with tumour size.
Laparoscopic surgery for PCC and PGL removal is associated with hypertensive emergencies which are amenable to usual doses of antihypertensives used intraoperatively. Surgical factors like tumour size and location affect the number of crisis and the dose of anti-hypertensives used more than the anaesthetic drugs and procedures.
We then discuss available pharmacological interventions suited for reducing blood pressure acutely. We also discuss specific blood pressure targets in common critical illnesses and consider future directions in this therapeutic area.
Dosing guidelines are available, although few pediatric-specific trials have been conducted to facilitate evidence-based therapy. Regardless of what medication is used, blood pressure should be lowered gradually to allow for accommodation of autoregulatory mechanisms and to prevent cerebral ischemia. Determining the underlying cause of the blood pressure elevation may be helpful in guiding therapy.