1) Welcome to a tweetorial on #hypertension management in #AorticDissection! Accredited for 0.50 CE/CME credits by @academiccme: physicians, nurses, pharmacists! Expert faculty @JerroldLevy. Hello @DocAnitaGupta, @LorraineC_MD, @WarnerMatthewA, @DrManiCTSurgery, @PatrickGoldste4 pic.twitter.com/0rhqllShFn
— cardio-met (@cardiomet_CE) March 26, 2021
3) 58F, 87kg, presents to ED with sudden sharp chest pain radiating to back. PMH: HTN with poor compliance. Initial BP 230/110 R arm, 220/100 L arm. HR 110s. O2 sat 94%. ECG: ST, LVH with strain. CXR: pic.twitter.com/yezN1R65nL
— cardio-met (@cardiomet_CE) March 26, 2021
5) Acute aortic dissection suspected. CVP and art lines placed. Careful neuro exam reveals no deficits. L radial pulse diminished compared with R.
— cardio-met (@cardiomet_CE) March 26, 2021
7) Lots to unpack re #AorticDissection (incidence 2.6-3.5/100,000 person years, 2/3 males), but let’s focus on acute BP management.
— cardio-met (@cardiomet_CE) March 26, 2021
9) Morphine is the usual parenteral analgesic of choice. It is anxiolytic, may slightly dampen BP but without causing reflex tachycardia, and can be titrated carefully. If ACS is a differential dx, sometimes we are confused because NTG may provide some analgesia.
— cardio-met (@cardiomet_CE) March 26, 2021
11) . . . most patients will require additional anti-hypertensive therapy to reach SBP goal of < 120mm Hg. Also, some patients can’t tolerate beta-blockade. Back-up and secondary options include CCBs, nitroprusside, or IV ACEi.
— cardio-met (@cardiomet_CE) March 26, 2021
13) Indicate your answer and please return tomorrow for poll results and further discussion. Shout-outs to @ProfHinkelbein @Ajar_Kochar @ogi_gajic @alimkakeng @DukeCTSurgery @ChrisTroianos
— cardio-met (@cardiomet_CE) March 26, 2021
15) We all know #nitroprusside. It is of course a fast-acting and generally reliable vasodilator. It should not be used before you have the arterial line in. It should NOT be used in our patient without a beta-blocker already on board to protect against reflex tachycardia.
— cardio-met (@cardiomet_CE) March 27, 2021
17) Another issue with #nitroprusside is potential toxicity of its metabolites. It is initially metabolized to cyanide, which is then metabolized in the liver to thiocyanate, which is then cleared by the kidneys . . .
— cardio-met (@cardiomet_CE) March 27, 2021
19) In the two cohort studies of nicardipine in the treatment of hypertensive emergency in acute #AorticDissection, it was reported that the drug has a rapid and beneficial effect on decreasing BP (Kyobu Geka – Japanese J Thorac Surg 1995;48:290-4; J Int Med Res 2002;30:337-45
— cardio-met (@cardiomet_CE) March 27, 2021
21) It is ultrashort acting with rapid onset and offset of effect. Importantly for predictability of effect, clevidipine reduces BP by decreasing arteriolar resistance without affecting venous capacitance vessels.
— cardio-met (@cardiomet_CE) March 27, 2021
23) In the ECLIPSE trials (Anesth Analg. 2008;107:1110–21), clevidipine was more effective than NTG or NTP and was similar to nicardipine for keeping SBP within target range.
— cardio-met (@cardiomet_CE) March 27, 2021
25) Finally, in an ED population managed largely without invasive BP monitoring, clevidipine was safe and effective in managing hypertensive emergencies of varying etiology. See VELOCITY led by @md_pollack, Ann Emerg Med. 2008;53:329-38.
— cardio-met (@cardiomet_CE) March 27, 2021
27) Welcome back to our accredited tweetorial on BP management in #AorticDissection. I am @JerroldLevy. Back to our case. This patient was started on IV esmolol and was titrated to a HR of 50-60, but BP remained 180/90 as CT confirmed the diagnosis.
— cardio-met (@cardiomet_CE) March 28, 2021
29) A small but interesting comparison of clevidipine vs nitroprusside as add-on therapy to esmolol in managing #AorticDissection-related hypertensive emergency was published in Am J Emerg Med (2017;35:1514-1518).
— cardio-met (@cardiomet_CE) March 28, 2021
31) Clevidipine showed similar efficacy to NTP as adjunct therapy to esmolol, but was also associated with lower drug costs.
— cardio-met (@cardiomet_CE) March 28, 2021
Try diuresis.
— cardio-met (@cardiomet_CE) March 28, 2021
Remember, volume overload should always be considered as a potential cause of ongoing hypertension especially in hypertensive urgencies and emergencies.
35) Other considerations include younger patients with normal ventricular function, who have a sympathetic hyperactivity, and blood pressure is difficult to control despite both beta-blockers and IV CCBs.
— cardio-met (@cardiomet_CE) March 28, 2021
37) One of the advantages of IV CCBs like clevidipine or nicardipine is that once blood pressure is well controlled, it facilitates transitioning of patients to oral therapy by continuing dihydropyridine CCBs such as amlodipine.
— cardio-met (@cardiomet_CE) March 28, 2021
38) So you made it! Free CE/#CME! Physicians, pharmacists, nurses: go to https://t.co/n8YexfiGwA and claim your FREE credit! I am @JerroldLevy. Follow @cardiomet_CE for more tweetorials. Please share with your colleagues! #medtwittter #cardiotwitter #CME
— cardio-met (@cardiomet_CE) March 28, 2021