Presentation by Dr Papadakos Knowledge resources at Scribe : www.scribeofegypt.com

1. How to Manage Hypertension 2008 PJ PAPADAKOS MD Director of Critical Care Medicine Professor of Anesthesiology, Surgery And Neurosurgery University of Rochester

2. University of Rochester Medical Center

5. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA . 2003;289:2560-2572. The JNC 7 Report  100  160 Stage 2 90-99 140-159 Stage 1 80-89 120-139 Prehypertension < 80 < 120 Normal Diastolic BP mm Hg Systolic BP mm Hg BP Classification

13. Pathophysiology

14. Regulation of Blood Pressure Blood Pressure Adrenergic Tone Baroreceptor Reflexes Volume/Pressure Renin/Angiotensin Preload Cardiac Output Catecholamines Adrenal Gland CNS Veins Arteries Capacitance Resistance Heart Kidney Afterload

16. Pathophysiology

17. Fibrinoid Necrosis

19. CT SCANS and X-rays

20. Hypertensive Encephalopathy/Retinopathy

21. Delanty et al Neurology 1997;49:686-689 Posterior leukoencephalopathy in hypertensive encephalopathy

23. Reversible high T2 signal abnormalities in pre-eclampsia

28. Aortic Dissection

31. A Precipitous and Uncontrolled Fall in BP Can Have Lethal Consequences Infarct …. brain, heart, kidney Cerebral Blood Flow 60 mm Hg 120 mm Hg 180 mm Hg Mean Arterial Blood Pressure Acute Chronic

34. Treatment 2008

35. Pharmacologic Approach to Hypertensive Emergencies JOB, JF ORMC 90

39. Beta-Blocker in Patients With Decreased Cardiac Output Decreased Contractile Force

45. Metabolism of Sodium Nitroprusside Tinker JH, Michenfelder JD. Anesthesiology . 1976;45:340-354. Inactive Cytochromes CN - TOXICITY Thiocyanate (SCN - ) Thiosulfate Renal Excretion Cytochrome Oxidases Hepatic Rhodanase Nitroprusside Nitroprusside Radical Oxyhemoglobin Methemoglobin Non-enzymatic Cyanmethemoglobin

48. NEJM . 1982; 306:1129. Survival Patients Rx with nitroprusside within 9 hours of AMI

49. Nitrovasodilators in Patients With Recent Stroke and Compromised Coronary Blood Flow Coronary Steal Syndrome

50. Nitrovasodilators in Patients With Decreased Cerebral Circulation and Compromised Coronary Blood Flow Decreased Cerebral Blood Flow

51. Nitrovasodilators Dilate Both Arterial and Venous Vessels NITROVASODILATORS - Hypotension - Reflex tachycardia - Exacerbated by volume depletion

52. Fenoldopam HO HO DOPAMINE NH · CH 3 SO 3 H OH HO HO Cl FENOLDOPAM MESYLATE NH 2 Highly selective DA 1 agonist

56. Renal and Hemodynamic Effects of Intravenous Fenoldopam Versus Nitroprusside in Severe Hypertension CrCl ml/Min Circulation . 1990;81:970.

58. Recommended Antihypertensive Agents for Hypertensive Emergency Fenoldopam or nicardipine Acute renal failure/ microangiopathic anemia Verapamil, diltiazem, or nicardipine in combination with benzodiazepine Sympathetic crisis/cocaine Labetalol or nicardipine Eclampsia Labetalol or combination of nicardipine or fenoldopam and esmolol or nitroprusside with esmolol/metoprolol Acute aortic dissection Labetalol, nicardipine, or fenoldopam Hypertensive encephalopathy Labetalol or esmolol in combination with nitroglycerin Acute myocardial ischemia Fenoldopam or nitroprusside in combination with nitroglycerin and loop diuretic Acute pulmonary edema Preferred agent(s) Condition

59. Calcium Channel Agents

61. Ca2+ inf lux Voltag e- Operated Ca2+ specific Receptor- O perated Ca2+ / Cation Ligand-Operated Ca2+/Cation Plasma membrane channels Ca2+ Mitochondrial Ca Uptake Sarco-/Endo-plasmic reticulum Ca Uptake Ca/Mg pump Na-Ca exchg.

62. Ca2+ I Ca Ca2+ Ca2+ Ca-pump CICR Sarcoplasmic reticulum L-type Channel Myofilament Voltage-operated Ca2+ Channel (VOCC) Electrical Impulse

63. IV Calcium Channel Blockers The relative effects are ranked from no effect (0) to most prominent (+++++). Adapted from Goodman and Gilman, 9th ed. McGraw-Hill;1996 and Massie, Am J Cardiol . 1997;80:231-321. ++++ +++++ ++ +++ Diltiazem 0 + 0 +++++ Nicardipine +++++ +++++ ++++ ++++ Verapamil Suppression of AV Node Suppression of SA Node Suppression of Cardiac Contractility Coronary Vasodilatation Compound

64. Dihydropyridine CCBs Cardene ® IV nicardipine Intravenous preparations 2nd Generation: Procardia ® , Adalat ® Cardene ® Norvasc ® DynaCirc ® Plendil ® Nimotop ® Sular ® nifedipine nicardipine amlodipine isradipine felodipine nimodipine nisoldipine Oral preparations 1st Generation: 2nd Generation: Brand Name Drug

67. Nicardipine vs Nitrovasodilators +++ ++ ++++ Ease of Administration 0 ++++ 0 Cyanide Toxicity +++ ++ + Hypotension ++ ++ + Tachycardia ++++ + +++ Coronary vasodilation 0 + 0 Coronary Steal ++++ ++ 0 Preload Reduction + ++++ ++++ Afterload Reduction ++++ ++++ ++++ Rapid Onset Vasodilator Vasodilator CCB Drug Class Nitrobid IV ® Nipride ® Nitropress ® Cardene ® IV Brand Name Nitroglycerin Nitroprusside Nicardipine

68. Nicardipine vs Adrenergic Blockers +/- Decreased Minimal increase HR Slower Rapid Rapid Offset Positive Positive Positive Myocardial O 2 Balance Labetalol (Normodyne) ® Esmolol (Brevibloc) ® Nicardipine (Cardene ® IV) Bolus Continuous infusion Bolus Continuous infusion Continuous infusion* Administration Rapid Rapid Rapid Onset Decreased 0 Decreased SVR +/- Decreased Increased Cardiac Output Severe bradycardia Heart block >1° Overt heart failure Cardiogenic shock Sinus bradycardia Heart block >1° Overt heart failure Cardiogenic shock Advanced aortic stenosis Contraindications

69. New For 2008 Including work of Dr Eaton at SMH

74. Postoperative Hypertension

85. JAMA . 1996;276:1328.

87. Recommended Antihypertensive Agents for Hypertensive Emergency Fenoldopam or nicardipine Acute renal failure/ microangiopathic anemia Verapamil, diltiazem, or nicardipine in combination with benzodiazepine Sympathetic crisis/cocaine Labetalol or nicardipine Eclampsia Labetalol or combination of nicardipine or fenoldopam and esmolol or nitroprusside with esmolol/metoprolol Acute aortic dissection Labetalol, nicardipine, or fenoldopam Hypertensive encephalopathy Labetalol or esmolol in combination with nitroglycerin Acute myocardial ischemia Fenoldopam or nitroprusside in combination with nitroglycerin and loop diuretic Acute pulmonary edema Preferred agent(s) Condition