Pharmacotherapy for hypertensive urgency and emergency in COVID-19 patients

BRASH syndrome is characterized by bradycardia, renal failure, AV nodal blockade, shock, and hyperkalemia. The proposed mechanism involves a vicious cycle between AV nodal blockers, hyperkalemia, and renal failure and was first described in 2016. We present a case of a 52-year-old woman who presented with progressively worsening shortness of breath and hypertensive urgency who subsequently developed profound bradycardia and shock that was refractory to resuscitative measures, she was diagnosed with BRASH syndrome. In this article, we explore the predisposing factors and challenges faced during the management of patients with BRASH syndrome.

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Abstract T3: Type 2 Myocardial Infarction Predicts Outcome In Hypertensive Crisis Patients: Nationwide Analysis

Hypertension ◽

10.1161/hyp.78.suppl_1.t3 ◽

2021 ◽

Vol 78 (Suppl_1) ◽

Author(s):

Ahmed M Maraey ◽

Ahmed Elzanaty ◽

Hadeer R Elsharnoby ◽

Mahmoud Salem ◽

Mahmoud Khalil ◽

...

Keyword(s):

Myocardial Infarction ◽

Hospital Mortality ◽

Hypertensive Crisis ◽

Primary Diagnosis ◽

Hypertensive Emergency ◽

Secondary Outcome ◽

Hypertensive Urgency ◽

Emergency Presentation ◽

The Impact

Background: Type 2 Myocardial infarction (T2MI) can occur in hypertensive crisis patients. The impact of T2MI in this population is poorly understood due to limited available data. Objective: To assess the impact of T2MI on patients admitted to the hospital with hypertensive crisis. Methods: We queried National Readmission Database (NRD) of year 2018 for adult patients admitted with a primary diagnosis of hypertensive crisis. Patients were excluded if they had type 1 myocardial infarction (T1MI), septic shock, or bleeding in the index admission. Primary outcome was 90-day readmission due to T1MI. Secondary outcome was in-hospital mortality. Subgroup analysis was done according to urgency and emergency presentation. Multivariate regression was done to account for confounders. Results: A total of 101211 patients were included in our cohort of whom 3644 (3.6%) were diagnosed with T2MI and 24471 (24.2%) were readmitted within 90 days of discharge. Of those, 912 (3.7%) were diagnosed with T1MI on readmission. T2MI was independently associated with increased odds of 90-day readmission with T1MI (Adjusted odds ratio (aOR): 2.67, 95% CI [1.91-3.75], P=0.000). T2MI effect was observed in hypertensive urgency, and in hypertensive emergency. T2MI was associated with increased in-hospital mortality in hypertensive urgency population (aOR: 4.21, 95% [1.58-11.25], P=0.004) but not in hypertensive emergency (table 1). Conclusion: In hypertensive crisis patients, T2MI was associated with increased 90-day readmission with T1MI. Aggressive management of cardiovascular risk factors and risk stratification should be considered at the time of diagnosis.

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Clinical and Pharmacological Approaches to the Prescription of Centrally Acting Antihypertensive Drugs for Uncontrolled Arterial Hypertension

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2020-10-18 ◽

2020 ◽

Vol 16 (5) ◽

pp. 815-821

Author(s):

A. V. Strygin ◽

B. E. Tolkachev ◽

A. O. Strygina ◽

A. M. Dotsenko

Keyword(s):

Arterial Hypertension ◽

Antihypertensive Drugs ◽

Hypotensive Effect ◽

Optimal Choice ◽

Clinical Settings ◽

Hypertensive Urgency ◽

Drug Of Choice ◽

Target Organs ◽

Life Threatening ◽

Hypertensive Therapy

Episodes of rapid increase in blood pressure due to uncontrolled arterial hypertension, previously known as a hypertensive urgency, is common clinical condition which many of practicing physicians are encountered daily. As a rule, these conditions are not life-threatening, however they could lead to target-organs damage if not promptly relieved. Therefore, clear evidence-based recommendations of optimal antihypertensive drug administration in these situations would provide more safe and effective therapy. Despite that, definite expert consensus regarding optimal choice of antihypertensive drugs to manage these patients have not been reached so far. The aim of the current review was to assess the results obtained from clinical trials regarding the safety and efficacy of moxonidine for urgent hypertensive therapy in patients with uncontrolled arterial hypertension admitted to emergency healthcare units as well as in those at the prehospital stage. Performed literature-based analysis revealed enough evidences proving that moxonidine can be administered in a single dose of 0.4 mg as a drug of choice in situations where prompt and stable hypotensive effect is desired. Results of comparative studies designed to closely match real clinical settings indicate that more adequate and sustainable therapeutic effect is achieved after moxonidine administration in comparison to other frequently used antihypertensive drugs.

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Abstract 13197: Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Outpatient Setting

Circulation ◽

10.1161/circ.132.suppl_3.13197 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Krishna Patel ◽

Laura Young ◽

Erik H Howell ◽

Bo Hu ◽

Shannon J Morrison ◽

...

Keyword(s):

Hospital Admissions ◽

Outpatient Setting ◽

Uncontrolled Hypertension ◽

Office Visits ◽

Hypertensive Urgency ◽

Admission Rates ◽

Coronary Syndrome ◽

Asymptomatic Patients ◽

Significant Difference ◽

Hypertensive Urgencies

Background: Hypertensive urgency is a commonly encountered outpatient problem. Prevalence and short term outcomes of this condition are unknown. JNC VII recommends aggressive BP control over several days. However, a small percentage of patients are sent to the emergency department. It is unknown whether hospital management of these patients is better than outpatient BP management. Methods: Retrospective cohort study of all patients presenting to an office in a large health care system from 2008-2013 with SBP ≥180mmHg or DBP ≥ 110mmHg. We excluded pregnant women and patients referred to the hospital for symptoms or treatment of other conditions. Patients were divided into 2 groups: those sent home and those referred to hospital. We recorded baseline demographic and clinical data. Propensity matched outcomes recorded included MACE (acute coronary syndrome, stroke/TIA) uncontrolled hypertension (≥140/90 mmHg) and hospital admissions. Results: Of 2,199,019 office visits, 58,583 (5%) had hypertensive urgency. Mean age was 63±15 yrs, 58% were females, 76% Caucasian, mean BMI was 31±8 kg/m2 and mean SBP and DBP were 182±16 and 96±16 mmHg. Only 426 (0.7%) patients were referred to the ED/hospital. On propensity matched analysis between the patients referred to the hospital and sent home, there was no significant difference in MACE events at 7 days (0% vs. 0.13%, p=1), 30 days (0.25% vs. 0%, p=1) or 6 months (0.5% vs. 0.13%, p=0.26). Compared to patients sent home, patients referred to the hospital had less uncontrolled hypertension at 1 month (81% vs. 88%, p=0.001) but not at 6 months (65% vs 69%, p=0.16). They also had higher 7- and 30-day hospital admission rates (8.5% vs. 4.9%, p=0.01; 11.8% vs 7.6%, p=0.02). Conclusion: Hypertensive urgency occurs commonly, but the rate of MACE in asymptomatic patients is very low. ED visits increased hospitalizations, but did not improve outcomes. Most patients with hypertensive urgencies still had uncontrolled hypertension at 6 months.

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Hypertensive Urgency in Tanzanian Adults: A 1-Year Prospective Study

American Journal of Hypertension ◽

10.1093/ajh/hpaa129 ◽

2020 ◽

Author(s):

Karl G Reis ◽

Raymond Wilson ◽

Fredrick Kalokola ◽

Bahati Wajanga ◽

Myung-Hee Lee ◽

...

Keyword(s):

Medication Adherence ◽

High Risk ◽

Prospective Study ◽

Low Income ◽

Hypertensive Crisis ◽

The United States ◽

Low Income Countries ◽

Improve Medication Adherence ◽

Hypertensive Urgency ◽

Poor Outcomes

Abstract BACKGROUND Hypertensive urgency is associated with a high risk for cardiovascular events and mortality in the United States and Europe, but data from low-income countries and interventions to improve outcomes are lacking. METHODS We conducted a 1-year prospective study of the prevalence and outcomes of hypertensive urgency (blood pressure (BP) ≥180 mm Hg/120 mm Hg without end-organ damage) in a busy outpatient clinic in Tanzania. RESULTS Of 7,600 consecutive adult outpatients screened with 3 unattended automated BP measurements according to standard protocol, the prevalence of hypertensive crisis was 199/7,600 (2.6%) (BP ≥180 mm Hg/120 mm Hg) and the prevalence of hypertensive urgency was 164/7,600 (2.2%). Among 150 enrolled patients with hypertensive urgency, median age was 62 years (54–68), 101 (67.3%) were women, and 53 (35%) were either hospitalized or died within 1 year. In a multivariate model, the strongest predictor of hospitalization/death was self-reported medication adherence on a 3 question scale (hazard ratio: 0.06, P < 0.001); 90% of participants with poor adherence were hospitalized or died within 1 year. CONCLUSIONS Patients with hypertensive urgency in Africa are at high risk of poor outcomes. Clinicians can identify the patients at highest risk for poor outcomes with simple questions related treatment adherence. New interventions are needed to improve medication adherence in patients with hypertensive urgency.

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Simultaneous Presentation of Crohn’s Disease and Takayasu Arteritis in a Teenage Patient

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709620977317 ◽

2020 ◽

Vol 8 ◽

pp. 232470962097731

Author(s):

Inna Polyakova ◽

Glen Iannucci ◽

Roshan George ◽

Anne Gill ◽

Dinesh Govind Patel ◽

...

Keyword(s):

Takayasu Arteritis ◽

Clinical Symptoms ◽

Simultaneous Presentation ◽

Hypertensive Urgency ◽

Positron Emission ◽

Blood Pressures ◽

Inflammatory Bowel ◽

Renal Doppler ◽

Tomography Scan ◽

Full Body

A 14-year-old female with no significant medical history presented with hypertensive urgency, in the setting of 4 to 6 weeks of diarrhea, abdominal pain, headaches, anemia, weight loss, and high blood pressures. Her evaluation revealed signs of a systemic inflammatory process that was most suspicious for inflammatory bowel disease. However, when her hypertension was evaluated with a renal Doppler ultrasound, there were signs of narrowing, stenosis, and hypoplasia that led to a diagnostic angiogram of the abdominal aorta. Full body positron emission tomography scan revealed multiple areas of stenosis and aortic thickening with enhancement compatible with Takayasu arteritis. She received prednisone, methotrexate, and infliximab with marked improvement in her clinical symptoms and inflammatory markers.

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