Investigations ● Advances ● Applications
Case Studies
in
Acute Hypertension
Edwin G. Avery, MD, CPI
Assistant Professor of Anesthesiology
Massachusetts General Hospital Heart Center
Harvard Medical School
Case Studies of Acute Hypertension
Case Study #1
Type A Aortic Dissection
www.radpod.org
Case Studies of Acute Hypertension
Case Study #1
Acknowledgement
Thank you to Dr. Michael England for
sharing this interesting case
Case Study 1: Type A Aortic Dissection
44-year-old female presents for surgical
correction of a Type A dissection
► HPI: presented to ED complaining of
sudden onset of severe chest pain and
shortness of breath.
► PHM/PSH: obesity
► Allergies: NKDA
► Medications: none
► Fam Hx: noncontributory
► ROS: unremarkable
www.edpma.com
Case Study 1: Type A Aortic Dissection
► General: anxious, grossly obese.
► Ht: 62 inches Wt: 102 kg
► VS: 141/45 (R=L); HR 80’s reg; Resp 18;
SpO2 96% RA
► Neuro: alert & oriented x3; no gross
deficits
► Pulmonary: B/L rales
► Cardiac: S1S2 reg, grade IV syst. murmur
► Extrem: 2+ palpable B/L UE & LE; no
edema
turbosquid.com
Case Study 1: Type A Aortic Dissection
Chem:
Heme:
141 112
4.0 24
20
1.2
<
110
10
ECG: no ischemic changes
CT:
TEE:
>
12.3
39
<
250 LFTs
WNL
Coags
WNL
Case Study 1: Type A Aortic Dissection
Diagnosis
Type A Aortic Dissection
w/severe aortic insufficiency
Management
► Immediate β-blockade
www.radiologyassistant.nl
► Control SBP with IV antihypertensive to prevent aortic
rupture & further extension of dissection
► Proceed to the OR for immediate surgical correction
(ascending aortic replacement, +/- AVR)
Case Study 1: Type A Aortic Dissection
Management
► β-blockade: reduces dP/dt
► IV antihypertensive: reduces shear
forces on the weakened aortic wall
► Surgical correction: reduces observed
Type A dissection mortality (~↑2% per
hour). Uncorrected in-hospital
mortality (58%) vs. surgically
corrected (27.4%)1.
Hagan et al. Jama 2000;283:897
www.radiologyassistant.nl
Case Study 1: Type A Aortic Dissection
In the OR
Case Study 1: Type A Aortic Dissection
In the OR
Time (HH:MM)
SBP Values (mm Hg) v. Time
:5
5
10
:4
5
10
:3
5
10
:2
5
10
:1
5
10
:0
5
10
9:
55
9:
45
9:
35
9:
25
9:
15
9:
05
8:
55
180
160
140
120
100
80
60
40
20
0
8:
45
SBP (mm Hg)
SBP Values (mm Hg) v. Time
Case Study 1: Type A Aortic Dissection
In the OR
CPB
Time (HH:MM)
SBP Values (mm Hg) v. Time
:5
5
10
:4
5
10
:3
5
10
:2
5
10
:1
5
10
:0
5
10
9:
55
9:
45
9:
35
9:
25
Incision
9:
15
9:
05
Induction
8:
55
180
160
140
120
100
80
60
40
20
0
8:
45
SBP (mm Hg)
SBP Values (mm Hg) v. Time
Case Study 1: Type A Aortic Dissection
In the OR – “The Zone”
SBP Values (mm Hg) v. Time
Induction
Incision
120
Time (HH:MM)
:5
5
10
:4
5
10
:3
5
10
:2
5
10
:1
5
10
:0
5
10
9:
55
9:
45
9:
35
9:
25
9:
15
9:
05
95
8:
55
8:
45
180
160
140
120
100
80
60
40
20
0
CPB
Case Study 1: Type A Aortic Dissection
In the OR – the drugs
NTG
SBP Values (mm
Hg) v.nitroglycerin
Time
SNP sodium nitroprusside
Incision
CLV clevidipine
NTG
SNP
Time (HH:MM)
:5
5
10
:4
5
10
:3
5
10
:2
5
10
:1
5
10
:0
5
10
9:
55
9:
45
9:
35
9:
25
9:
15
9:
05
CLV
8:
55
8:
45
180
160
140
120
100
80
60
40
20
0
Induction
CPB
Case Study 1: Type A Aortic Dissection
In the OR – the drugs
NTG
SBP Values (mm
Hg) v.nitroglycerin
Time
SNP sodium nitroprusside
Incision
CLV clevidipine
NTG
SNP
Clevidipine dose
adjustment
Time
(HH:MM)(mg/hr)
:5
5
10
:4
5
10
:3
5
10
:2
5
10
:1
5
10
10
:0
5
8
9:
55
6
9:
45
4
9:
35
2
9:
25
0
9:
15
10
9:
05
CLV
8:
55
8:
45
180
160
140
120
100
80
60
40
20
0
Induction
CPB
Case Study 1: Type A Aortic Dissection
Summary
The ultra-short acting dihydropyridine calcium
channel blocker, clevidipine, can be used to safely
and effectively manage the acute hypertension that
accompanies one of the most morbid and
potentially mortal disorders of the cardiovascular
system.
Case Studies of Acute Hypertension
Case Study #2
Acute Coronary Syndrome
http://library.med.utah.edu
Case Studies of Acute Hypertension
Case Study #2
Acknowledgement
Thank you to Dr. Charles Pollack at the
University of Pennsylvania for sharing this
interesting case
Case Study #2: Acute Coronary Syndrome
►58 y/o male presents to ED with
chest pain of acute onset radiating
to left jaw and shoulder,
accompanied by SOB
►Triage vital signs were pulse
92/min, resp 24/min, and BP
212/126 mm Hg
►PMH included known CAD, CHF,
and hyperlipidemia
►ECG performed in Triage
http://mykentuckyheart.com
Case Study #2: Acute Coronary Syndrome
Acute Anterior STE Myocardial Infarction
Case Study #2: Acute Coronary Syndrome
► Physical examination: symmetrical
bounding pulses, diaphoresis, and
rales in both lung bases
► Management:





ASA 325 mg
Clopidogrel 600 mg
Unfractionated heparin by IV infusion
Nitroglycerin by IV infusion
Beta-blockers are held because of
concern over heart failure
www.etopiamedia.net
► Prior to cath lab transfer: recheck BP is
196/118; and patient is diagnosed with
STEMI + Hypertensive Emergency
Case Study #2: Acute Coronary Syndrome
Hemodynamic Control
Blood Pressure vs. Time & Heart Rate
Blood Pressure
(mmHg)
225
170
175
SBP
DBP
160
125
HR
75
0
2
4
6
8
10
Time (minutes)
12
14
16
Case Study #2: Acute Coronary Syndrome
Hemodynamic Control
225
196
192
188
176
175
168
166
162
162
125
75
0
2
4
6
8
10
Time (minutes)
12
14
16
12
10
8
6
4
2
0
Clevidipine (mg/hr)
Blood Pressure vs. Time & Heart Rate
SB
DB
HR
Case Study #2: Acute Coronary Syndrome
Summary
Clevidipine can be used safely and effectively to care for
a patient with an acute coronary syndrome using a
peripheral IV and a blood pressure cuff. There was no
evidence of coronary steal or worsening of this patient’s
chest pain. Target BP control was obtained in less than
10 minutes.
Case Studies of Acute Hypertension
Case Study #3
Aortic Valve Replacement
Case Study 3: Aortic Valve Replacement
78-year-old male presents for
aortic valve replacement
► HPI: presented with symptoms of
shortness of breath and DOE.
► PHM/PSH: AS, MI, CAD (stents x2), HTN
(brittle), Chol, TIAs secondary to
spontaneous cholesterol emboli
► Allergies: NKDA
► Medications: metoprolol
► Fam Hx: noncontributory
► ROS: as per HPI o/w unremarkable
Case Study 3: Aortic Valve Replacement
► General: fatigued appearing
► Ht: 72 inches Wt: 90 kg
► VS: 128/62 (R=L); HR 60’s reg; Resp 18;
SpO2 98% RA
► Neuro: alert & oriented x3; no gross
deficits
► Pulmonary: CTA bilaterally
► Cardiac: S1S2 reg, grade IV syst. murmur
► Extrem: 2+ palpable B/L UE & LE; no
edema
Case Study 3: Aortic Valve Replacement
Chem:
Heme:
139 103
4.5 24
25
1.3
<
91
ECG: no ischemic changes
TEE:
Aortic stenosis (AVA 0.7 cm2),
gradient (P 51/M 32 mmHg w/CI 2.9
L/min/m2)
14.1
> 41.2 <
6.8
172
LFTs
WNL
Coags
WNL
Case Study 3: Aortic Valve Replacement
Diagnosis
Severe Aortic Stenosis with left
ventricular hypertrophy
Management
► Surgical aortic valve replacement with a bioprosthesis
► Control heart rate, maintain NSR, manage SBP with an IV
antihypertensive to prevent LV wall stress and MVO2,
avoid hypotensive overshoots
Case Study 3: Aortic Valve Replacement
In the OR
Case Study 3: Aortic Valve Replacement
In the OR
250
200
150
SBP
DBP
100
50
0
Heart Rate
Case Study 3: Aortic Valve Replacement
In the OR - The Zone
Induction
250
Intubation
Incision
200
CPB
F
F
150
SBP
DBP
100
50
Heart Rate
2
4
8
16
2
0 2 4
0
Clevidipine (mg/hr)
F- Fentanyl bolus
0
Case Study 3: Aortic Valve Replacement
Summary
Clevidipine can be used safely and effectively to
provide hemodynamic support for patients with
complex cardiovascular disease profiles (i.e. need
to strictly ovoid overshoot hypotension [AS] &
reflex tachycardia [AS, LVH, CAD]). Target BP
control was expeditiously obtained and maintained
in this patient.