@TYWangMD @CMichaelGibson @MkosiborodMD @SVRaoMD @DrMauricioCohen @EvieMarcolini @cpcannon @DLBHATTMD @SABOURETCardio @mmamas1973 @SantosGallegoMD @GoggleDocs #FOAMed #cardiotwitter @CardioNerds @JerroldLevy @ShelleyZieroth @RobHarrisonMD @mirvatalasnag @aayshacader @ErinMichos
— cardio-met (@cardiomet_CE) July 23, 2021
TOMORROW for a case presentation in which STEMI presents with pic.twitter.com/1GqCZsdxic
— cardio-met (@cardiomet_CE) July 26, 2021
And check out other accredited tweetorials "unrolled" at https://t.co/kwyzpVYUmG on hypertensive emergency and stroke by @EvieMarcolini and https://t.co/9YZbokox7x on hypertensive emergency by @JerroldLevy. OMG FREE #CME/CE everywhere! pic.twitter.com/6ktLo0uo1r
— cardio-met (@cardiomet_CE) July 26, 2021
. . . this accredited educational activity is intended for healthcare providers and is supported by grants from AstraZeneca, Bayer, Chiesi, and NovoNordisk.
— cardio-met (@cardiomet_CE) July 27, 2021
3) May I suggest a few? "Uh oh." "Oh, crap." "Page the #cathlab." "Page the #CCU." "WHAT did you say the blood pressure was? 224/168???" "Well, at least he came by that #LVH honestly."
— cardio-met (@cardiomet_CE) July 27, 2021
5) . . . but you risk doing more harm than good if you OVER-correct that BP. We need, first, an #antihypertensive that is parenteral, and second, we need a drug that is highly predictable and highly titratable.
— cardio-met (@cardiomet_CE) July 27, 2021
7) Which of these is NOT an adrenergic inhibitor?
— cardio-met (@cardiomet_CE) July 27, 2021
9) Unopposed alpha blockade in our patient would be potentially dangerous because it could drop the pressure too much, causing sudden HYPOperfusion of the at-risk myocardium and other vital organs. So just HOW much is TOO much?
— cardio-met (@cardiomet_CE) July 27, 2021
11) In this case we have another target for timing: a door-to-balloon time of 90 minutes or less for #primaryPCI, so for SO many reasons we want to act quickly to reduce that BP. His MAP now at 224/168 is a whoppin' 187. A 25% reduction is ~47, so in that . . .
— cardio-met (@cardiomet_CE) July 27, 2021
13) So back to our poll. We were looking at adrenergic blockers for hypertensive crisis. We also noted earlier that predictability and titratability (duration of action < 30 min) of the IV antihypertensive is key in this case. Which of the following likely best fills that bill?
— cardio-met (@cardiomet_CE) July 27, 2021
15) Welcome back to this #tweetorial on managing severe #hypertension in #STEMI presentation! I am @md_pollack and I am happy you found the ONLY source for serialized accredited tweetorials in #cardiometabolic care! @TYWangMD @gcfmd @vbluml
— cardio-met (@cardiomet_CE) July 28, 2021
17) esmolol treatment statistically significantly⬇️troponin, CK, CK-MB and NT-proBNP release in patients with STEMI undergoing #primaryPCI. These patients were NOT severely hypertensive, tho, and the goal of the study was to look at how esmolol provides tight sympathetic control.
— cardio-met (@cardiomet_CE) July 28, 2021
19) On the other hand, labetalol isn't as fast-acting (nor as quick off-set, making overshoot BP correction more dangerous) as esmolol. For our case we should look at vasodilators, too.
— cardio-met (@cardiomet_CE) July 28, 2021
21) The potential adverse effects of blithely bottoming out his BP are too worrisome. Plus there's the whole wrap-the-line-in-foil thing, the whole cyanide thing, the rapid tolerance, the concern for patients with renal dysfunction . . . Don't go there. pic.twitter.com/yw4X9u4B59
— cardio-met (@cardiomet_CE) July 28, 2021
23) . . . but we need something more precise for BP control, leading us to the CCBs, the go-to management for hypertensive emerg due to great PK, minimal adverse effects, and generally predictable hemodynamic response. We use dihydropyridine CCBs to inhibit L-type receptors . . .
— cardio-met (@cardiomet_CE) July 28, 2021
25) aren't as effective at acute, controlled BP⬇️and are negative chronotropes. That leaves us with nicardipine and clevidipine for a patient like ours, with STEMI and a sky-high BP.
— cardio-met (@cardiomet_CE) July 28, 2021
27) Mark your answer and return tomorrow for discussion and wrap-up! @CardioNerds @glennoettinger @beaverspharmd @JerroldLevy @brian_hiestand @hvanspall @aayshacader @mirvatalasnag #STElevation #medtwitter #FOAMed #MedicalTwitter #MedStudentTwitter #ACPTwitter #Cardiology 🫀 pic.twitter.com/d2shiKxvRB
— cardio-met (@cardiomet_CE) July 28, 2021
29) So the answer to yesterday's question is 1&2. Clevidipine has an ultra-rapid onset of 1-4 min vs nicardipine's onset of 5-10 min, allowing for more frequent dose titrations to carefully achieve a BP goal.
— cardio-met (@cardiomet_CE) July 29, 2021
31) On the other hand, clevidipine's ultra-fast onset makes frequent fine dose titrations safe and its short (5-15 min) duration of action reduces the risk of acute and delayed problems. Clevidipine is also safer in case of liver dysfunction than is nicardipine . . .
— cardio-met (@cardiomet_CE) July 29, 2021
33) . . . cardiac decompensation, it is important to note that use of a nicardipine infusion, at the usual conc of 25mg/250mL and an infusion rate of 15mg/hr, a 24h infusion would comprise 3.5L/d. The max infusion of clevidipine is 1L/d.
— cardio-met (@cardiomet_CE) July 29, 2021
35) On the other hand, clevidipine is dosed in a lipid emulsion and so must be used with caution in pts with allergy to soy or eggs or with defective lipid metabolism. Also, some inexperienced clinicians may be uncomfortable with the rapid (aggressive!) titration regimen:
— cardio-met (@cardiomet_CE) July 29, 2021
37) . . . lengthen the time between dose adjustments to every 5-10 minutes. Good rule of 👍: expect that each 1-2 mg/h dose ⬆️will generally produce an additional 2-4 mmHg ⬇️in SBP. In summary for our patient, urgent but carefully controlled reduction in severe hypertension . . .
— cardio-met (@cardiomet_CE) July 29, 2021
39) We'd be remiss if we didn't mention other measures that might help control this pt's BP. An anxiolytic and/or analgesic with help reduce sympathetic tone; morphine can do both, but stay at judicial doses (say, 2-4mg then 2mg increments PRN up to total 10mg or so max) . . .
— cardio-met (@cardiomet_CE) July 29, 2021
41) . . . not more and more antihypertensives. This is more common in dialysis patients, which ours in not, but worthwhile to ✅with thorough history and bedside ultrasonography. You hate to realize later that you missed the low hanging 🫐 . . .
— cardio-met (@cardiomet_CE) July 29, 2021
42) That's it! You made it! Free CE/#CME! #Physicians, #nurses, #pharmacists: go to https://t.co/Wvp2lURVgb and claim your credit! I am @md_pollack. Follow us for more tweetorials! #Medtwitter #MedEd @MedTweetorials #CardioTwitter #FOAMed #pharmacisttwitter @CardioNerds
— cardio-met (@cardiomet_CE) July 29, 2021