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Acute Severe Hypertension
20 Plays6 years ago
In this episode of Critical Matters, we will discuss the latest evidence, the proper management and potential pitfalls of acute severe hypertension.
Our guest is Dr. Aldo Peixoto. Dr. Peixoto is Professor of Medicine in the Section of Nephrology at the Yale University School of Medicine. He is also Vice Chair for Quality & Safety (Department of Internal Medicine) and Clinical Chief of the Section of Nephrology.
Additional Links:
Most recent US guidelines for the diagnosis and treatment of hypertension: http://bit.ly/39XlOFJ
European position paper on management of hypertensive emergency: http://bit.ly/35G8eTT
Severe Hypertension: http://bit.ly/2shwldW
Books Mentioned in this Episode:
Blindness by Jose Saramago: https://amzn.to/30863ak
Portuguese Irregular Verbs by Alexander McCall Smith: https://amzn.to/35ARai4
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
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Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
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And now your host, Dr. Sergio Zanotti.
Focus on Acute Severe Hypertension
00:00:32
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Acute severe elevations in blood pressure can cause significant morbidity due to organ injury.
00:00:38
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Furthermore, elevations in blood pressure are commonly seen in the hospital setting and are often mismanaged by clinicians.
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In today's episode of the podcast, we will discuss the latest evidence, the proper management, and potential pitfalls of acute severe hypertension.
Meet the Expert: Dr. Aldo Peixoto
00:00:52
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Our guest is Dr. Aldo Peixoto.
00:00:54
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Dr. Peixoto is a professor of medicine in the section of nephrology at the Yale University School of Medicine.
00:01:00
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He is also vice chair for quality and safety, Department of Internal Medicine, and clinical chief of the section of nephrology.
00:01:06
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His research interests include secondary and refractory forms of hypertension.
00:01:10
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He has published more than 100 peer-reviewed articles and book chapters in nephrology and hypertension, and is the author of a book on bedside diagnosis.
00:01:18
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He is an associate editor of Blood Pressure Monitoring and is on the editorial board of the American Journal of Nephrology and the Brazilian Journal of Nephrology.
00:01:26
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Dr. Peixoto is a recognized clinician, researcher, and medical educator.
00:01:30
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We are honored to have him as our guest.
00:01:32
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Aldo, welcome to Critical Matters.
00:01:35
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Thank you very much.
00:01:36
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It's a pleasure to be here, Sergio.
Understanding Acute Severe Hypertension
00:01:39
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So I think that we could maybe start by just if you could give us an overall introduction to acute severe hypertension in terms of is it frequent, what do we know about it today, and then maybe we can start diving into some of the definitions.
00:01:55
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Sure.
00:01:56
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So acute severe hypertension, which is the term that I chose to borrow from others to define both or to include both hypertensive emergencies and urgencies, and we can define them a little better in a second, is broadly described a blood pressure that's over a certain threshold, and the arbitrary threshold that's being used is 180 for systolic
00:02:23
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and either 110 or 120 for diastolic.
00:02:28
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This is very common.
00:02:29
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It's a very common cause of visits to emergency departments throughout the world.
00:02:36
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It's a very common cause for admissions, and it's a problem that is of interest to emergency physicians, critical care specialists,
00:02:48
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cardiologists, hospitalists.
Hypertensive Emergencies vs. Urgencies
00:02:50
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So I thought it was a very, always have thought of it as a very important topic to discuss.
00:02:58
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Absolutely.
00:02:58
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And I think it's one of those things, as we'll see, that even though we see frequently and we encounter a lot, often gets mismanaged in both directions, both over and under treatment.
00:03:09
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And I think that centralizing or focusing on some of the basic concepts that can guide our therapeutic conduct, I think, is always a good place.
00:03:18
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So could you give us, Aldo, maybe a little bit more precise definitions?
00:03:22
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And you did mention a little bit when you talked about the umbrella of hypertensive crisis and some numbers that, as you said, are arbitrary.
00:03:31
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But I think an important distinction really has to do with hypertensive emergency and everything else, or what some people call hypertensive urgency.
00:03:39
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How would you define these two?
Role of Organ Damage in Hypertensive Classification
00:03:41
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Very good.
00:03:42
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So if we start with a certain value, let's pick 180 over 120.
00:03:47
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And then the next step is really to define whether there is acute target organ damage.
00:03:58
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So if there is acute target organ injury, we call that an emergency.
00:04:02
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If there is no acute target organ damage, then it becomes an urgency.
00:04:09
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and so so it's important to define number one that the target organ injury is acute not chronic and obviously it needs to be an injury to an organ that's typically affected by hypertension and and that is the brain the heart the large vessels the kidneys the microvascular and one include would include the findings in the retina as part of this uh microvascular injury so
00:04:37
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If there is evidence of acute brain dysfunction, and whether that is due to an acute stroke, an acute intracerebral hemorrhage, or hypertensive encephalopathy, or if there's evidence of acute cardiac involvement, such as an acute coronary syndrome or acute decompensated heart failure, involvement of large vessels, and that's predominantly acute aortic dissection, acute renal involvement, so
00:05:06
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acute renal failure caused by severe hypertension.
00:05:10
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Chronic kidney disease can be caused by hypertension, but here it's important that it be
ICU Care for Hypertensive Emergencies
00:05:16
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recognized as an acute problem, which is typically part of microvascular involvement, which can be diagnosed either by the changes in the kidney that can happen acutely or by microangiopathic hemolytic anemia or by some of the findings in the retina, such as the acute
00:05:37
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retinopathy changes such as hemorrhages, exudates, and ultimately papilledema.
00:05:43
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So when these findings are present, findings of acute target organ damage exist, then we label those patients as having an emergency.
00:05:53
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And that has pretty significant implications to what we do with those patients.
00:06:00
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Those patients belong in the intensive care unit.
00:06:03
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They should not be managed on the floor.
00:06:06
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they should be treated promptly with IV drugs.
00:06:11
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And, you know, you're going to select the drugs according to the specific indications.
00:06:16
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You're going to lower the blood pressure following a pattern.
00:06:20
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I think we'll get to that later in our conversation.
00:06:23
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But what's important is that those patients be at a high level of monitoring, that they be treated with IV drugs.
00:06:31
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Most of them should have
00:06:33
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an arterial line to monitor their blood pressure.
00:06:37
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And this is a very select group of patients that really require aggressive therapy.
00:06:45
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In the absence of acute target organ damage, then that's when we can actually do harm by over-treatment.
Terminology and Treatment Approaches
00:06:56
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And in those patients, the approach to therapy is different and should focus
00:07:03
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on the if the patients have symptoms related to the blood pressure, let's say patients have a headache, patients have a let's say epistaxis, something that's that's acutely bothering them, we might want to try to control their blood pressure a little faster just to make them feel better.
00:07:23
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But the the ultimate goal is really to adjust longer acting medications,
00:07:28
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So, and obviously through oral therapy, not intravenous therapy.
00:07:33
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And those patients very often don't belong in the emergency room, don't belong in the hospital, but they need to receive intensive outpatient therapy.
00:07:43
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And I think that this is an important paradigm that is not followed that frequently.
00:07:53
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And that's a point that I always think is important to make.
00:07:57
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Absolutely, and I think that one question I have regarding the term of hypertensive urgency, I know that I've always found the construct useful, especially in explaining to others, but also in terms of my therapeutic approach.
00:08:14
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But I do know that lately it has become or fallen in disfavor, and some people really just say, focus on the emergencies.
00:08:21
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Everything else is just hypertension.
00:08:23
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Any comments on that, Aldo?
00:08:25
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I think that that's the big push for that is because if you hear urgency, it still has an urgent tone to it, right?
00:08:38
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And what ends up happening is that people think that those patients should be sent from the office to the emergency room, should be brought in from the emergency room.
00:08:49
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into the hospital, from the emergency room into the hospital, sometimes even into a step-down or ICU unit.
00:08:57
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And that's why the name has, the term has been, it has been proposed that they, that it not be used because those patients really
Challenges in Blood Pressure Measurement
00:09:07
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should be treated as outpatients in a fairly aggressive way, but still as outpatients.
00:09:14
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And with that, I fully agree.
00:09:17
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Whether changing terminology will help in moving that agenda forward and changing the paradigm, that's arguable.
00:09:27
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I decided in writing recently about this, I decided to maintain the term urgency just because it's easier to drive the discussion, not because of one thing or another.
00:09:43
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I would not oppose that.
00:09:44
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eliminate this focus on emergencies and eliminating the term urgency and just defining the fact that if someone has a blood pressure that is at that kind of level, that the management in the outpatient setting should be done in a fairly intensive way.
00:10:03
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Absolutely.
00:10:04
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And I think that it's just important also to be coherent with our treatments.
00:10:09
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And I think that one of the pitfalls I often see is not recognizing
00:10:14
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that somebody has acute organ damage and not implementing the appropriate therapies.
00:10:20
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And then the other extreme is over treating people who don't have acute organ damage and be putting them at risk for damage from our treatment.
00:10:28
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So you talked about the two elements that define the hypertensive emergency, which are an elevation in blood pressure and the presence of acute organ damage.
00:10:37
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Could you talk a little bit more, Aldo, about proper measurement of blood pressure?
00:10:42
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which I think, I mean, is the first step, obviously, in terms of trying to figure out if somebody's hypertensive.
00:10:48
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I think that that is a major issue because at very high blood pressure levels, and when you start seeing systolics above the 180 range and diastolics above 100 to 110, the
00:11:08
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validating protocols that are used to validate most oscillometric devices that we use in most hospitals, emergency rooms and offices, those protocols don't hold as well because it's hard to find people that walk around with blood pressures of 220 over 120 in the ambulatory setting to participate in the study.
00:11:33
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So the validation protocols of the algorithms for these oscillometric devices hold very well in the range of systolic pressures between 90 to about 180, and especially 160.
00:11:48
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They hold well for diastolics in the 60 to 100, 105 range, but really lose accuracy afterwards.
00:12:02
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In the ICU population, post-operative population, this has been relatively well studied.
00:12:09
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And we know that when you get to systolic blood, to blood pressures in the range of what we call acute severe hypertension, there tends to be an underestimation of the intra-arterial pressure by these oscillometric devices.
00:12:26
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So you may be, and that the average underestimation may be as high as 50 over 30.
00:12:32
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So this is a significant problem.
00:12:35
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And then on the lower end of the pressure range, there is an overestimation of blood pressure, not of this magnitude, but still present.
00:12:45
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So bottom line, the same way as critical care specialists very often resort to putting an A-line to monitor someone who's on pressers,
00:12:56
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to make sure that they are guiding the blood pressure, the use of vasopressor agents well in the low pressure range, the same holds here.
Causes of Acute Severe Hypertension
00:13:06
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And if you're going to be using intravenous agents, you should have a very precise measurement of blood pressure.
00:13:13
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And therefore, these patients who have hypertensive emergencies, who get admitted to the ICU, in whom acute target organ damage exists,
00:13:23
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those patients deserve an A-line for more precise blood pressure measurement and treatment titration.
00:13:32
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And this lack of performance at extremes
00:13:36
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is not solved when you use a manual mercury string on a manometer if you're an old school person.
00:13:42
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Unfortunately not.
00:13:43
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Yes.
00:13:47
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Obviously, we don't even have mercury manometers, but it was a problem with mercury.
00:13:51
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It is a problem with aneroids.
00:13:53
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The accuracy of these devices and the use of a sculptatory technique doesn't improve that
00:14:03
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difference and that bias that's observed when compared to intra-arterial.
00:14:08
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So there's not only a problem in validating algorithms with oscillometric devices, but also an accuracy measurement when using auscultatory methods.
00:14:22
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Excellent.
00:14:23
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I think this is an important point because the presence, again, of acute organ damage is what should be dictating
00:14:29
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whether we bring somebody to the ICU, we use IV, we are more precise with our measurements, and identifying that, as we'll talk a little bit later, is really the key to this discussion.
00:14:39
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In terms of pathophysiology, Aldo, what causes acute severe hypertension?
00:14:45
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So, it can be caused by just about anything that causes hypertension.
00:14:50
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So, when we talk about pathophysiology specifically, that would be too broad a discussion.
00:14:56
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You know, you can have
00:14:58
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in the setting of acute microvascular injury, for example, pressure-induced injury, and the term that we used to use very often of malignant hypertension.
00:15:07
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So these patients, the acute injury to the renal microvascular drives a lot of this, and there's a very extensive activation of the renal angiotensin system.
00:15:18
Speaker
And in other situations, the mechanisms are going to be predominantly adrenergic,
00:15:25
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So, for example, acute presentations in pheochromocytoma would be a great example of that.
00:15:31
Speaker
So I prefer to look at it less from a pathophysiologic mechanism specifically.
00:15:39
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But I think in a clinical discussion, what's more valuable is to review what typical causes exist.
00:15:49
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And one thing is very obvious.
00:15:51
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the majority of patients who present with acute severe hypertension have a diagnosis of hypertension.
00:15:59
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That number is 80 to 90, sometimes even higher, 90% of cases.
00:16:04
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So these are people who already have a known diagnosis of hypertension and then present typically in a setting of not having taken medications.
00:16:15
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This is consistent across many observational studies
00:16:19
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And in different countries, this is not a United States problem.
00:16:22
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This happens around the world.
00:16:25
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So in someone who has, who comes in with this and gives you a history of not taking medications regularly, you know, ran out of medications, someone stopped meds and started a new treatment that's not exactly right, you're going to pick most cases just by this technology.
00:16:48
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And there really isn't, you should not be running to try to make a diagnosis of a secondary cause immediately in these patients.
00:16:59
Speaker
You might have to get back to it in case they are indeed resistant to therapy.
00:17:04
Speaker
But just the very fact that they presented with acute severe hypertension doesn't mean that you need to go look for secondary causes.
00:17:15
Speaker
any of the typical secondary causes, and we could go down the list of renal parenchyma, renal vascular, adrenal cortical, so primary aldosteronism in its various presentations, adrenal medullary, so especially the rare cases of pheochromocytoma, so on and so forth.
00:17:37
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We could go down the list of secondary causes of hypertension.
00:17:41
Speaker
Those need to be thought about
00:17:44
Speaker
when people present with acute severe hypertension without having a previous history of hypertension.
00:17:50
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In those cases, I would argue your threshold to rule out secondary causes should be much lower.
00:17:58
Speaker
But in those that already have a history of hypertension and who report decreased adherence, and people are often very candid in telling you that, in those patients you should probably focus first on management
00:18:10
Speaker
And then if they become resistant, just as you would do in anybody with resistant hypertension in the ambulatory setting, you would then trigger the evaluation of secondary hypertension.
00:18:21
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Does that answer your question?
00:18:24
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Absolutely, absolutely.
00:18:26
Speaker
And in terms of other precipitants that could also cause severe elevations in blood pressure that wouldn't be secondary or wouldn't be lack of taking medications,
00:18:37
Speaker
Can you mention some that we should think about at least when we see the patients in the ED or
Pathophysiological Mechanisms
00:18:41
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for the first time?
00:18:41
Speaker
Yes.
00:18:42
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Yes.
00:18:43
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So the most important ones are related to in patients who have salt-sensitive hypertension.
00:18:50
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Sometimes you have the combination of increased salt intake.
00:18:54
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So you start with not as well-controlled blood pressure that is salt-sensitive.
00:18:59
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So, for example, in African-Americans, in patients with underlying kidney disease, in patients who are older,
00:19:07
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And then you add to that an acute salt load, and often with another common precipitant, drugs are common precipitants, and then another class of drugs that can further enhance salt sensitivity, which are non-steroidals.
00:19:22
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So you could have that kind of perfect storm.
00:19:24
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You already start at a higher pressure.
00:19:26
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You eat a large salt load and take some NSAID for whatever reason.
00:19:32
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That's that often precipitate.
00:19:34
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The drugs that can be looked at as secondary causes are also very important, especially sympathomimetic drugs, so very important to think about them.
00:19:48
Speaker
And sometimes patients may be triggered on this one when they go on high-dose steroids, especially, again, if they are salt-sensitive and already poorly controlled to begin with.
00:19:58
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So thinking of medications is very important, and in salt-sensitive patients,
00:20:05
Speaker
A high sodium load is also something that very often throws patients into an episode of acute severe hypertension.
00:20:16
Speaker
Excellent.
00:20:17
Speaker
And Aldo, I think from a perspective of what causes organ damage, really, obviously, there's a lot that we don't fully understand, but a lot of it centers around two, I think, important aspects.
00:20:29
Speaker
One is out of regulation, and the other one has to do with
00:20:34
Speaker
endothelial injury, right?
00:20:36
Speaker
Can we talk a little bit about auto-regulation curves and how you view them from your perspective and ultimately how I think they have implication for the way we approach these patients?
00:20:46
Speaker
Sure.
00:20:47
Speaker
So I think that if we, so the best way we should probably just define auto-regulation first, which is the ability of a, so there are changes in arteriolar tone
00:21:03
Speaker
to modulate perfusion of an organ.
00:21:06
Speaker
So with vasodilatation in the low blood pressure ranges so that all the organ perfusion can be enhanced and vasoconstriction on the high end ranges to prevent pressure induced tissue injury.
00:21:21
Speaker
So the organs with this has significant importance in the setting of acute severe hypertension are
00:21:32
Speaker
Primarily, well, let's say three.
00:21:34
Speaker
The brain is by far the most important because of the concern about symptoms and injury related to the brain on both ends.
00:21:46
Speaker
So if blood pressure goes too low, obviously cerebral hyperperfusion, and that would be a complication of therapy.
00:21:53
Speaker
And if blood pressure goes too high and supersedes the autoregulation on the high end,
00:22:01
Speaker
then the symptoms associated with severe hypertension, such as cerebral edema causing hypertensive encephalopathy, focal cerebral edema causing, for example, posterior reversible encephalopathy, and obviously hypertension-associated strokes.
00:22:23
Speaker
In the kidney, that loss of autoregulation is also important because
00:22:30
Speaker
some of the microvascular injury that occurs in the kidney will then drive the process of malignant hypertension and acute kidney injury related to high blood pressure.
00:22:42
Speaker
The vasculature itself doesn't have an autoregulatory process because blood is flowing.
00:22:50
Speaker
And the microvascular injury, the extent of
00:22:54
Speaker
not only endothelial, but also injury to the wall happens by a variety of mechanisms.
00:23:04
Speaker
But during the exposure to very high blood pressure, you have extensive injury to the vascular wall.
00:23:12
Speaker
And in the part related to the endothelium, you have this process in the microvascular church that then
00:23:21
Speaker
is one of the mechanisms of generating a microangiopathic hemolytic anemia in which pressure-induced injury to the endothelium leads to microvascular injury, and these patients develop microangiopathic anemia with thrombocytopenia in a way that's classic and just the same as you would see with other mechanisms of endothelial injury, and this one just happens to be a pressure-induced injury.
00:23:51
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So this defines the importance of autoregulatory curves in mediating the complications in the brain, in the kidney, the endothelial injury for developing the MAHA-type presentation.
00:24:06
Speaker
And then the last one that's worth remembering is the heart, just because, especially in patients with acute coronary syndromes, that we need to be very cautious of what the diastolic blood pressure is doing.
00:24:19
Speaker
That doesn't really have to do much with auto regulation, but just has to do more with patterns of myocardial perfusion pressure and the concerns with excessive reduction of diastolic pressure in patients with acute coronary syndromes.
00:24:36
Speaker
So the next important concept to understand is that when we talk about treatment,
00:24:45
Speaker
understanding the autoregulatory curves to the brain, I think that the most important to understand, and it's also the best studied, is essential to define where we can go in terms of treatment.
00:25:00
Speaker
We need to remember that patients with chronic hypertension shift their autoregulatory curves to the right.
00:25:08
Speaker
So that affords them greater protection against very high pressures.
00:25:15
Speaker
but puts them at risk of cerebral hypoperfusion at blood pressures that wouldn't be too concerning for most of us.
00:25:27
Speaker
And so usually we don't worry about mean arterial pressures of 85 causing problems to anybody.
00:25:35
Speaker
But in a hypertensive with a very rightward shifted autoregulatory curve, that might be already
00:25:42
Speaker
in a range where they may have cerebral hyperperfusion.
00:25:48
Speaker
And then one last comment, Sergio, that I think might be worth making is that in patients who have an acute de novo hypertension, who were previously very normal tensive, they may develop significant brain cerebral edema
00:26:11
Speaker
related to pressures that are not as high as we would usually worry about.
00:26:19
Speaker
So those are people who can have a hypertensive emergency with a blood pressure that's less than 180 over 110 or over 120.
00:26:28
Speaker
Classic examples of that would be preeclampsia, eclampsia.
00:26:35
Speaker
Younger patients, especially kids with
00:26:40
Speaker
with acute glomerulonephritis and pheochromocytoma crisis.
00:26:44
Speaker
So these are important exceptions to just, you know, there are some people who are very fixated on a number.
00:26:51
Speaker
And, you know, don't sit on a young preeclampic woman who maybe two weeks ago had never seen a blood pressure above whatever, 100 over 65, who now has a blood pressure of, you know,
00:27:08
Speaker
165 over 120 and you're not worried because the, or let's say 165 over 110, and you're not worried because it doesn't pass muster or doesn't cross the thresholds of the binary criteria that people develop.
00:27:24
Speaker
So I think that those are some of the important points that I wanted to make about auto regulation.
00:27:32
Speaker
And I think just to emphasize, it's very important
00:27:36
Speaker
to think about the numbers in the right context because I think it's very easy for a clinician to anchor their decision-making to an objective number.
00:27:44
Speaker
And like you said, in a young preeclamptic patient, maybe not be too concerned because, oh, it's only 160 over 110.
00:27:51
Speaker
Yet for that patient, that rapid increase has exceeded their ability to auto-regulate and is causing acute organ damage.
00:27:58
Speaker
And the converse, I guess, is also true is you see 180 over 110 in somebody who is chronically hypertensive, not taking their medications,
00:28:06
Speaker
And we've jumped to bring that down.
00:28:09
Speaker
And by doing that, we can cause more harm.
00:28:11
Speaker
So really focusing more on what it means for that patient and the presence or absence of acute organ damage.
00:28:18
Speaker
I think that's really where the auto-regulation curves and understanding them really come to play.
00:28:23
Speaker
Absolutely.
00:28:26
Speaker
So let's talk about therapeutic management.
00:28:29
Speaker
And really, obviously, there's multiple ways you could approach this.
00:28:34
Speaker
But based on the conversation that we've had so far, Aldo, it really seems that a sentinel decision point in terms of intervening from an intensivist perspective with an IV drug aggressively in an ICU centers around the presence of acute organ damage.
00:28:53
Speaker
Could you tell us how you approach a patient with severe acute hypertension in determining do they have organ damages from a very practical standpoint?
00:29:03
Speaker
Yeah.
00:29:04
Speaker
So, obviously, the main one is to look for symptoms, right?
00:29:10
Speaker
So, someone who has obvious findings, let's say obvious clinical symptoms to suggest a stroke, whether ischemic or hemorrhagic, visual changes to suggest press, chest pain to suggest an acute coronary syndrome or a dissection, shortness of breath to suggest
00:29:33
Speaker
acute decompensated heart failure.
00:29:36
Speaker
And in the basic labs that one would get, if there is acute renal failure and you would suspect that this is, and you have reason to suspect that that's new, so those would be, or let's say a new microangiopathic hemolytic anemia that wasn't present previously.
00:29:54
Speaker
So those are pretty obvious.
00:29:56
Speaker
The ones that the tougher distinction is in the absence of symptoms, right?
00:30:03
Speaker
Because the quality of laboratory tests and diagnostic tests to identify findings and the value, the sensitivity, and especially the specificity of these findings is difficult to interpret.
00:30:22
Speaker
So I use an approach that leaves room for discussion.
00:30:29
Speaker
But let's be pragmatic.
00:30:32
Speaker
So for example, if the screening neurological exam is negative and a fundoscopic exam, which I still do, I really do, is normal.
00:30:48
Speaker
I don't pursue anything further in terms of brain evaluation.
00:30:53
Speaker
In the heart, if the patient has a normal clinical exam and does not have shortness of breath, I very often don't even do a chest X-ray.
00:31:03
Speaker
In the ER, everybody's gonna get a chest X-ray.
00:31:08
Speaker
I do not know how to do echoes, so I don't carry a butterfly in my pocket.
00:31:14
Speaker
And if I did, I might take a look at the heart, although there are no data to show that that makes any difference.
00:31:21
Speaker
Same thing as doing BNPs.
00:31:23
Speaker
If the patient doesn't have symptoms suggestive of heart failure, a BNP has no value.
00:31:29
Speaker
The issue of doing troponins or not, I do an EKG on everybody, but without real certainty that that's of any value.
00:31:39
Speaker
If in the emergency room,
00:31:41
Speaker
patients get a troponin, and I'm very reassured if a troponin is normal.
00:31:46
Speaker
If a troponin is mildly abnormal, it not necessarily means that the patient has an acute coronary syndrome.
00:31:55
Speaker
It may be just a evidence of chronic injury, and that's a point of contention.
00:32:01
Speaker
Most patients that I end up seeing, either if I'm
00:32:06
Speaker
If it's in the hospital and I'm attending on the medical service or if it's someone that I go to the ED to see in the emergency room, those patients will have a troponin.
00:32:16
Speaker
But there's certainly room for contention there.
00:32:20
Speaker
In the presence of symptoms, then obviously we will guide the diagnostic evaluation based on
00:32:29
Speaker
as I discussed briefly before, on whatever you find.
00:32:34
Speaker
And then the modality, typically, of imaging will be guided by the symptoms.
00:32:40
Speaker
In the kidney, it's worth mentioning that if there is acute kidney injury, the likelihood, then the distinction that needs to be made is, is this a primary renal disease that's causing the hypertension?
00:32:55
Speaker
Or is this the hypertension causing kidney injury as part of the malignant hypertension syndrome, if you will?
00:33:02
Speaker
And that is not always, you know, very often it's a difficult diagnosis that you can only sort out by a kidney biopsy.
00:33:12
Speaker
Because even if you see a lot of red cells in the sediment, a lot of proteinuria, it could still be a malignant hypertension causing renal failure.
00:33:25
Speaker
rather than the other way around.
00:33:26
Speaker
So that is very often a difficult one to do without a kidney biopsy.
00:33:32
Speaker
And for microangiopathic hemolytic anemia, typically it would follow the typical work of MAHA.
00:33:38
Speaker
And I don't think I have ever seen someone present with severe hypertension with only MAHA.
00:33:48
Speaker
They usually have something else, typically renal failure,
00:33:51
Speaker
along with it, I've never seen someone present just with, let's say, hemolytic anemia and thrombocytopenia and nothing else as part of their presentation of severe hypertension, hypertension emergency.
00:34:07
Speaker
So that's my usual approach to diagnosis.
00:34:11
Speaker
What do you do?
00:34:12
Speaker
I want to, well, I take a similar approach.
00:34:17
Speaker
I think it's, well, I can tell you what you do that I don't do is a fundoscopic exam and that's shame on me, but I wanted to talk about that.
00:34:24
Speaker
So the two things that you mentioned that I wanted to dive a little bit more into are the fundoscopic exam and you talked about the butterfly.
00:34:33
Speaker
So on the butterfly, what I wanted to ask you before we go to detail in the fundoscopic exam is that more and more clinicians, especially in the ED and the ICU are proficient with ultrasound, are carrying ultrasound.
00:34:46
Speaker
And it's not something that I have done regularly, but I have seen studies suggesting that measuring the width of the optic nerve is a good correlate of ICP, increased intracranial pressure, or papilledema.
00:35:04
Speaker
Have you seen any of that?
00:35:06
Speaker
Could that be like the millennial fundoscopic exam?
00:35:10
Speaker
Any thoughts on that, Aldo?
00:35:12
Speaker
So I do not know the specific paper or papers that you're referring to in terms of optic nerve width.
00:35:18
Speaker
I have not read any such paper.
00:35:21
Speaker
There is a very good amount of knowledge of studies looking at arteriolar diameter.
00:35:30
Speaker
And as a measure of chronic hypertensive injury so as a pretty good correlate for hypertensive vascular injury, but that's all in the realm of chronic hypertension.
00:35:42
Speaker
I'm not aware of of anything in the acute hypertension injury, but it just means that I haven't seen those papers the the value that I see of endoscopy is that if you do not see
00:36:01
Speaker
uh exudates hemorrhages it gives you a a sense that the microvascular is holding on to that blood pressure pretty well and and i i i feel reassured about that uh on the other hand if someone who's asymptomatic and i'm looking at their fundus and i see exudates i see hemorrhages i may even see a little bit of papilledema
00:36:27
Speaker
that that's someone that I'm going to be very worried about.
00:36:31
Speaker
And fortunately, we see those very, very infrequently.
00:36:35
Speaker
There's a there's a device and I have no conflict of interest on this.
00:36:39
Speaker
There's a device that you can attach to your phone and that takes excellent pictures of the fundus.
00:36:47
Speaker
I do not have that device, but I've seen it being used.
00:36:52
Speaker
It provides really great pictures.
00:36:54
Speaker
And it has the advantage that you can share the pictures.
00:36:57
Speaker
Not only you get a good view of the fundus, but you can just, if you have an ophthalmologist that you can just send the images to, you'd have an extra layer of reassurance that what you looked at is exactly what you're thinking about.
00:37:16
Speaker
So most of all, what I do is with the ophthalmoscopes that I have in the room,
00:37:20
Speaker
rather than this, and this provides something that's useful.
00:37:24
Speaker
I just haven't spent the money to buy one for me.
00:37:28
Speaker
So, and I think it's important because obviously photoscopic examination is a lost art, and I think that people use it less and less.
00:37:37
Speaker
I mean, I would be surprised to find a resident or a fellow carrying an ophthalmoscope in his lab coat today.
00:37:47
Speaker
I would be very surprised if I find that.
00:37:49
Speaker
It's more likely that they have a butterfly like you mentioned.
00:37:52
Speaker
But clearly, the presence of severe grade three or grade four retinopathy, it's a red alarm.
00:38:00
Speaker
It's a signal that something needs to be done, that this patient is at high risk.
00:38:05
Speaker
And I think, like you said, the absence or presence is something that is very, very valuable in maybe directing therapy in some of these patients.
00:38:15
Speaker
And I think it's something that we should probably encourage people to think about, especially in the setting of the ED, which they should have a fundoscope that we could utilize to look at this.
00:38:26
Speaker
And I will definitely investigate more on that phone device, which sounds very, very intriguing, not something that I know much about.
00:38:34
Speaker
Now, you did mention retinopathy.
00:38:37
Speaker
The other thing that you mentioned, which I think constitutes with retinopathy, the too often forgotten acute organ damage,
00:38:44
Speaker
is the microangiopathic hemolytic anemia.
00:38:47
Speaker
And this is something I think a lot of times people tend to forget about and not think about, but clearly also, I mean, in some situations, it could be, I mean, an indicator that something requires immediate treatment.
00:39:00
Speaker
Could you comment a little bit more about how you differentiate microangiopathic hemolytic anemia from hypertension, from other syndromes that I'm sure you'd get called for, HUS or other symptoms,
00:39:12
Speaker
associated with this phenomenon?
00:39:15
Speaker
Yeah, so there will be, you know, HUS is a bad one to pick, right, because hypertension so often complicates HUS.
00:39:23
Speaker
Renal failure is uniformly a part of the presentation.
00:39:28
Speaker
So that makes it very hard.
00:39:30
Speaker
And that's going to be similar to the issue of what you do with, you know, a primary glomerulonephritis versus renal failure related to malignant hypertension.
00:39:42
Speaker
So in that one, it may be that your answer is going to come from control of blood pressure and cessation of the microangiopathy.
00:39:53
Speaker
So improvement in platelet counts and improvement in hemoglobin as you control the blood pressure better.
00:40:03
Speaker
The evaluation is the typical one of how you'd approach a patient with a
00:40:12
Speaker
microangiopathy with a hemolytic with suspicion of a hemolytic anemia so after the screen is positive you know whatever LDH is high heptoglobin is low platelets are low looking at a peripheral smear and then if there is because if you end up with someone who's encephalopathic with or without some LFT abnormalities and by the way you can see there are rare reports of hepatitis in the setting of a
00:40:40
Speaker
of hypercellular injury, let's call it hypercellular injury in the setting of malignant hypertension.
00:40:46
Speaker
So in those patients, you might end up even having to send an ADAMS-13 as part of the evaluation of a possible TTP syndrome.
00:40:56
Speaker
And so that evaluation is one that's going to depend on the severity of the process, how quickly you have to make a decision about the diagnosis,
00:41:06
Speaker
very often involving a hematologist so you can have a good input about what the peripheral smear looks like and if there's anything else that we may be missing.
00:41:16
Speaker
And then usually as you have these results coming back in, you can get an ADAMS 13 level pretty quickly.
00:41:24
Speaker
We as nephrologists are looking at the urine sediment
00:41:27
Speaker
the hematologist is giving a perspective from theirs.
00:41:32
Speaker
And in the meantime, the blood pressure is coming down, and then we can identify if this is part of the hypertensive emergency syndrome or if there's something else that's driving the process.
00:41:47
Speaker
In pregnancy, obviously, the issue is a little different.
00:41:49
Speaker
And fortunately, the delivery usually takes care of these things.
00:41:58
Speaker
And I think that you had asked, I mean, what would I, what do I approach it?
00:42:01
Speaker
And I think that the approach is, like I said, is very similar.
00:42:03
Speaker
And to be honest, although what I find is that I think is an important point is that a lot of times I will evaluate these patients in the ED.
00:42:11
Speaker
And more often than not, everything that I need has been ordered already as part of the routine workup.
00:42:17
Speaker
So it's really just, I mean, using those basic things to very quickly
00:42:21
Speaker
in a systematic way, eliminate the evidence of organ failure or presence, and that ultimately decides where the patient needs to go and what we need to do.
00:42:29
Speaker
The one thing that I wanted to get your thoughts on, and actually this is probably the highlight of my career as a fellow in terms of consultations, was recognizing in a patient that they were about to start an IV drip that he had a big prostate.
00:42:47
Speaker
and had a very, very large bladder.
00:42:49
Speaker
And my suggestion in a very tongue-in-cheek way to the ED attending was instead of the nicotapine, I would put a Foley in.
00:42:58
Speaker
And that took care of the blood pressure.
00:43:01
Speaker
Any comments on things that we need to make sure that we eliminate before we start treating the blood pressure?
00:43:06
Speaker
Yes.
00:43:07
Speaker
So, in your, so enlargement of the, you know, a full bladder.
00:43:15
Speaker
full undrained bladder is a cause of hypertension in anybody it will be a very it's a cause of severe hypertension in patients who have dysautonomia especially patients with autonomic dysreflexia due to spinal cord you know high spinal cord injuries so in those you're gonna see blood pressures that are truly phenomenal with just a an undrained bladder or
00:43:42
Speaker
or sometimes just with constipation.
00:43:46
Speaker
It's amazing the impact.
00:43:49
Speaker
But a large bladder can drive very high blood pressures on just about anybody, especially if you have pain.
00:43:55
Speaker
So the corollary to that is that severe pain from anything, since in patients, especially patients who already have a diagnosis of hypertension, the adrenergic surge related to that can very often cause very high
00:44:11
Speaker
blood pressures.
00:44:12
Speaker
So treat pain first before you reach to the, you know, let's say intravenous drugs to manage the hypertension.
00:44:22
Speaker
The same thing is true for shortness of breath.
00:44:26
Speaker
So in decompensated heart failure, sometimes it's not the hypertension that's driving the heart failure.
00:44:33
Speaker
It's the heart failure and then the adrenergic surge related to the hypoxia
00:44:39
Speaker
that's driving the blood pressure.
00:44:40
Speaker
And sometimes just control of volume promptly brings the blood pressure down.
00:44:45
Speaker
Obviously, fortunately, the treatment ends up being the same.
00:44:50
Speaker
So you can take both.
00:44:51
Speaker
But don't be surprised if just correction of resolution of pulmonary edema is enough to control the blood pressure and the hypertension doesn't remain for very long.
00:45:04
Speaker
Excellent.
00:45:05
Speaker
So if we determine that the patient has evidence of acute organ damage, as you mentioned earlier, these are patients that require aggressive treatment with IV drugs, likely benefit from an A-line and definitely should be treated in monitor settings like an ICU.
00:45:22
Speaker
How do you know how much to lower the blood pressure?
00:45:24
Speaker
How do you think about the target mean arterial pressure, Aldo?
00:45:28
Speaker
So there's a couple of things that you need to take into account for that.
00:45:34
Speaker
The first one is you're going to use pathophysiologic principles.
00:45:41
Speaker
You're going to use some lessons from the autoregulatory curves and what we've known from experiments in humans looking at this and make decisions about what is safe based on the autoregulatory curve.
00:45:55
Speaker
So that's the first point.
00:45:57
Speaker
The second point is specific to the individual conditions.
00:46:02
Speaker
Many of these specific recommendations are opinion-based.
00:46:07
Speaker
They are not based on trial data.
00:46:10
Speaker
The only, so we have okay data in the setting of ischemic stroke and reasonable data in the setting of intracerebral hemorrhage.
00:46:22
Speaker
For everything else, the decisions are largely driven by, you know,
00:46:31
Speaker
presumed pathophysiology and clinical observations.
00:46:36
Speaker
So let's go maybe one by one, if you will, of the major clinical sense.
00:46:42
Speaker
Absolutely.
00:46:43
Speaker
So, for example, for patients who have diffused microvascular damage, or as used to be called malignant hypertension, and patients who have hypertensive encephalopathy,
00:46:59
Speaker
So severe hypertension with microvascular injury and or a hypertensive encephalopathy.
00:47:06
Speaker
Those patients, you bring the blood pressure down and you respect the autoregulatory curve.
00:47:15
Speaker
So what are some principles?
00:47:16
Speaker
So that would be sort of the most generic reduction.
00:47:21
Speaker
So you can bring the blood pressure down by about 25% or so in the first
00:47:29
Speaker
hour.
00:47:30
Speaker
It's generally safe.
00:47:34
Speaker
If you do not bring the blood pressure down by more than 30% or so, you rarely get to the inflection point on the lower end of the auto-regulatory curve.
00:47:46
Speaker
Since we're not looking at graphics, let me tell you exactly what I'm meaning.
00:47:51
Speaker
So if you bring the blood pressure, as you bring the blood pressure down, there will be a point where
00:47:58
Speaker
where the auto regulation is lost.
00:48:00
Speaker
And at that time, cerebral perfusion will fall fairly abruptly.
00:48:07
Speaker
How abruptly it falls has a very large inter-individual variation.
00:48:13
Speaker
So you cannot predict what that is.
00:48:15
Speaker
But that point of an abrupt decrease rarely occurs
00:48:23
Speaker
at levels that are less than about 25 or so, 30% of reduction from where the blood pressure was at the time you started treating.
00:48:34
Speaker
So that's what gives you that cushion of safely bringing the blood pressure down by about 25%.
00:48:41
Speaker
That's where the golden number of 25% reduction of either systolic or menial pressure comes from.
00:48:50
Speaker
So that you can do within the first hour.
00:48:53
Speaker
It's probably okay.
00:48:54
Speaker
Some people want to be a little more conservative and bring it down within two hours.
00:48:59
Speaker
I think that in most patients, bringing it down in one hour is good enough and safe enough.
00:49:06
Speaker
So you bring that and then over the ensuing two to six hours or so, you try to bring the blood pressure to about
00:49:18
Speaker
let's say 160 over 100 or thereabouts.
00:49:21
Speaker
And most of the hypotensive events will occur in those first six hours.
00:49:30
Speaker
So at that time, you just play with the IV drugs.
00:49:34
Speaker
And if the patient does well in those first six hours, and definitely if you want to be conservative the first six to 12 hours, then that is the time you start adding oral drugs.
00:49:48
Speaker
so you don't have to stay given intravenous drugs for too long.
00:49:52
Speaker
And as the oral drugs, the long-acting oral drugs start acting, then you're able to wean the antihypertensives down.
00:50:03
Speaker
And your goal would be to reach your target blood pressure, whatever the target blood pressure is, arguably getting the patient down to the hopefully 140 over 90 range
00:50:15
Speaker
by the 48, 72 hour mark.
00:50:19
Speaker
So that would be sort of the most generic approach.
00:50:23
Speaker
But then you have the specific other situations.
00:50:26
Speaker
So as I told you, in stroke, we have more data.
00:50:32
Speaker
So there's a little bit of a better way to, you know, guidance to this.
00:50:39
Speaker
And in, for example, in hemorrhagic stroke,
00:50:44
Speaker
If the blood pressure is in the 150 to 220 range, there is no general agreement, by the way.
00:50:54
Speaker
Not even when I talk to our stroke neurologists, they don't agree among each other.
00:50:58
Speaker
They sometimes think that I'm too aggressive.
00:51:01
Speaker
They have told me that I am at times.
00:51:04
Speaker
And I'll tell you what I've written as a general statement that I got general agreement.
00:51:11
Speaker
is that if the blood pressure starts, systolic starts in the 150 to 220, bring it down to about 140 to 150.
00:51:20
Speaker
And you can do that fairly safely within the first hour.
00:51:25
Speaker
And that's particularly true for patients who do not have a history of hypertension.
00:51:33
Speaker
You don't want to delay it too much for people who do not have known hypertension.
00:51:38
Speaker
And in those who have, for example, an AVM or an aneurysm, because you want to control them well.
00:51:47
Speaker
In patients who have a very large hematoma or who have otherwise evidence of increased intracranial pressure, then you might want to be a little more conservative because those patients will be at risk of ischemia in the perihemorrhage area.
00:52:08
Speaker
So there is a formal recommendation that the systolic blood pressure should not come down below 140 because in those patients there were worse outcomes in one of the two large trials.
00:52:22
Speaker
So in the ATTACH-2 trial, there was harm in bringing the blood pressure below 140.
00:52:29
Speaker
So for cerebral hemorrhage, there is relatively good guidance on this.
00:52:36
Speaker
For ischemic stroke, then it varies according to whether the patient's gonna get thrombolytic therapy or not.
00:52:42
Speaker
If the patient's eligible for thrombolytic therapy, then the reduction would be to less than 185 over 110 before they can get the thrombolytics, and then it's kept at less than 180 over 105, at least for the first day.
00:52:58
Speaker
And if thrombolytic therapy is not gonna be used, then it's a little more liberal.
00:53:05
Speaker
And as long as the blood pressure is less than 220 over 120, then no intervention happens for the first two, three days.
00:53:14
Speaker
And that's largely because of concerns of excessive blood pressure reduction and extension of infarct because of the sensitive, the poor auto-regulation of the peri-infarct penumbra or the infarct penumbra.
00:53:29
Speaker
And then...
00:53:34
Speaker
A very important thing with stroke, with ischemic stroke, is that these people often have other complications.
00:53:43
Speaker
So they may come in also with heart failure or they may have an acute coronary syndrome.
00:53:50
Speaker
So if there is other target organ injury, then the management of the other target organ damage injury will also be factored here.
00:54:02
Speaker
So there may be patients with stroke
00:54:04
Speaker
that may have to be treated more aggressively because they have heart failure or because they have an acute coronary syndrome.
00:54:11
Speaker
Then for the three last well-defined syndromes would be in acute coronary syndromes, there is a suggestion.
00:54:20
Speaker
There are no strong data to back this up to decrease the systolics to less than 140, and you can do that within one hour.
00:54:31
Speaker
Just got to be careful with keeping the diastolic above 60 to not worsen coronary perfusion.
00:54:37
Speaker
In heart failure, the general agreement is to bring the systolic down to less than 140.
00:54:42
Speaker
Also do that promptly within one hour.
00:54:45
Speaker
Again, no data to back that up.
00:54:48
Speaker
And then finally, the often nightmares of aortic dissection.
00:54:53
Speaker
in which the goal is to both decrease the systolic blood pressure promptly, right?
00:54:59
Speaker
You bring it down to less than 120, so it's both prompt and aggressive, but also not forgetting to decrease the heart rate to limit the amount of aortic injury, so promptly also decreasing the heart rate to less than 60.
00:55:16
Speaker
So those are the general principles.
00:55:19
Speaker
And for every one of these,
00:55:21
Speaker
you will start oral therapy somewhere after that 12-hour period or so so that it allows you to titrate the oral medications off as the patients progress.
00:55:40
Speaker
And I think that's a very important point that I often see people misunderstand.
00:55:45
Speaker
The idea of starting is you obviously are very aggressive up front.
00:55:49
Speaker
You stabilize them.
00:55:51
Speaker
But the idea of starting the oral medications in that 6 to 12-hour window is so that you can effectively wean them off the drip in 24 to 36 hours.
00:56:01
Speaker
It doesn't mean that you're going to stop the drip at 12 hours or at 6 hours.
00:56:05
Speaker
And I think that's an often, I think, source of confusion.
00:56:08
Speaker
I see people basically control for 24 hours, and then they start, and then they wonder why the patient's still in the ICU.
00:56:15
Speaker
That's correct.
00:56:18
Speaker
So we talked about when to initiate aggressive treatment, which is the presence of organ failure and how to identify that.
00:56:24
Speaker
We talked about the targets based on our understanding of auto-regulation and the available evidence, which you mentioned is very lacking in general, but only available for some syndromes.
00:56:36
Speaker
Let's talk about drugs, Aldo.
00:56:38
Speaker
And I know that there's not a lot of good studies that show that one drug is superior to another, if any.
00:56:46
Speaker
Some studies have paired
00:56:48
Speaker
drugs head-to-head, but just in terms of titration.
00:56:51
Speaker
But how do you think about drugs and what are your general recommendations?
00:56:58
Speaker
So as you said, there are no, there are very limited data in terms of outcomes.
00:57:06
Speaker
We know we have very good control with calcium channel blockers, especially nicardipine and clavidipine.
00:57:16
Speaker
Those are excellent drugs.
00:57:18
Speaker
I had never used clavidipine until about a month ago, and then we've had a shortage in the cardipine.
00:57:24
Speaker
I used clavidipine in three patients in the last month, so that was a curiosity.
00:57:31
Speaker
And it's a very convenient drug.
00:57:34
Speaker
It's short-acting.
00:57:37
Speaker
I like short-acting drugs because it gives me flexibility to control the blood pressure.
00:57:43
Speaker
So...
00:57:47
Speaker
And these are drugs that have excellent control in clinical trials.
00:57:52
Speaker
Libetolol also has done fairly well in clinical trials.
00:57:57
Speaker
It has the advantage that you can both use bolus and drips.
00:58:01
Speaker
So it's a convenient drug to use.
00:58:04
Speaker
It's well-tolerated.
00:58:06
Speaker
And those are the workhorses, right?
00:58:10
Speaker
Nucardipine, libetolol.
00:58:12
Speaker
As I said, I didn't have any personal experience
00:58:15
Speaker
With clavidipine, our anesthesiologists use quite a bit, but in the CCU and ICU, clavidipine wasn't used very much.
00:58:23
Speaker
Esmolol is an important drug as part of the management of this section.
00:58:28
Speaker
Nitroglycerin, very important in the management of patients with acute coronary syndromes and heart failure.
00:58:35
Speaker
And these are the workhorses.
00:58:36
Speaker
I used a lot of nitride in the past.
00:58:40
Speaker
Nipride has become, obviously, there are the risks of toxicity in patients with prolonged infusions, patients with kidney disease, patients with liver disease.
00:58:49
Speaker
But also, it has become tremendously, almost prohibitively expensive.
00:58:53
Speaker
So nitroprosite has not been used very often, at least in our institution, for several years.
00:59:03
Speaker
So these are really the workhorses.
00:59:06
Speaker
The decision of which one to use will be guided primarily by the pattern of injuries.
00:59:13
Speaker
So if you have, you know, diffuse microvascular injury or hypertensive encephalopathy, most people can be managed well with either labetalol or necartipine.
00:59:23
Speaker
Nipride is an alternative.
00:59:25
Speaker
For hypertensive encephalopathy, it's the same.
00:59:29
Speaker
For patients with intracerebral hemorrhage or acute stroke, the same.
00:59:35
Speaker
Our neurointensivists really prefer nicardipine, so most patients end up being managed with nicardipine first.
00:59:44
Speaker
And then the acute coronary syndromes are largely with nitroglycerin, and obviously they end up getting a beta blocker along with the nitroglycerin.
00:59:55
Speaker
For heart failure, they get diuretics along with the nitroglycerin.
01:00:01
Speaker
And for dissection, most patients get
01:00:03
Speaker
a combination of Esmolol and Nicaridapine or Esmolol and Nipride.
01:00:13
Speaker
So those are really driven by the underlying process and personal preferences.
01:00:22
Speaker
And one comment that I really think is important to make is that aside from heart failure, hydralazine really should be, or
01:00:32
Speaker
aside from heart failure and pregnancy.
01:00:35
Speaker
Hydralazine really should not be used.
01:00:37
Speaker
It's a drug that gives us unpredictable responses, sometimes excessive.
01:00:44
Speaker
It really should not be used in patients with hypertensive encephalopathy and patients with stroke.
01:00:49
Speaker
But I would argue that aside from heart failure, especially heart failure with reduced ejection fraction, and
01:00:59
Speaker
in pregnancy that we should eliminate intravenous hydralazine.
01:01:04
Speaker
I really feel strongly about that.
01:01:06
Speaker
And it's probably the most commonly used, and I would say most commonly overused, antihypertensive in our hospital.
01:01:14
Speaker
Absolutely.
01:01:15
Speaker
And I think that even when you look at pregnancy in terms of safety and in terms of what we're trying to achieve from the blood pressure perspective, it really offers no advantage over something like nicardipine.
01:01:27
Speaker
So in terms of the patients in my ICU, I would always favor using something like nicardipine over hydralisine, which, like you mentioned, is unpredictable, has a long half-life, and is probably not a good drug to use from the risk of lowering the blood pressure too much.
01:01:44
Speaker
And I think that's ultimately what we're trying to avoid in these patients.
01:01:49
Speaker
And I think you mentioned clavidipine, and just for the listeners, obviously, clavidipine is a shorter-acting calcium channel blocker.
01:01:55
Speaker
Like you said, it's very, very prevalent.
01:01:58
Speaker
in the operating room.
01:02:00
Speaker
Most of the initial studies were done in intra-op and post-op patients.
01:02:06
Speaker
And I think that the reality is it's probably not as prevalent in a lot of our ICUs just because of a cost issue compared to nicardipine.
01:02:14
Speaker
But I do think that as that eventually might change, a lot of our listeners might have that available as well.
01:02:21
Speaker
And because it's shorter acting, it might allow for more precise titration or more rapid titration,
01:02:28
Speaker
even though there's no proven outcome benefit, might be beneficial from just a practice standpoint.
01:02:37
Speaker
So I think that as we're closing, Aldo, are there any special clinical situations that we didn't talk about?
01:02:44
Speaker
Maybe something that's not as common or a zebra or something in particular that you want to mention?
01:02:50
Speaker
Yeah, so, you know, so for example, patients who come in with cocaine intoxication avoid beta blockers.
01:02:58
Speaker
I would probably even avoid libetalol.
01:03:00
Speaker
You have other options.
01:03:02
Speaker
And if you think that the cocaine is part of the hypertensive emergency, you should probably avoid libetalol and certainly avoid beta blockers that do not have an alpha blocking activity.
01:03:17
Speaker
So, you know,
01:03:19
Speaker
That's one.
01:03:19
Speaker
The second one is, you know, let's not get into the pregnancy management.
01:03:24
Speaker
That's a completely different disease.
01:03:28
Speaker
And for those patients, you know, the rapidity of management is important.
01:03:34
Speaker
The delivery is important.
01:03:37
Speaker
Everybody should get magsulfate, et cetera, et cetera.
01:03:40
Speaker
So it's a different kettle of fish.
01:03:42
Speaker
And, you know, the rare zebra ones, there will be patients that you might see
01:03:49
Speaker
with who have, you know, a few chromocytoma crisis.
01:03:58
Speaker
You know, it's a rare disease.
01:04:00
Speaker
It's a disease you don't want to miss.
01:04:03
Speaker
And those patients are really best managed with fentolamine, right?
01:04:09
Speaker
And so the rapid initiation of fentolamine
01:04:14
Speaker
And then as soon as the blood pressure is better controlled, then add in a beta blocker, but only after they are well alpha blocked.
01:04:22
Speaker
Fortunately, most of those patients are diagnosed in the outpatient setting, but you definitely don't want to miss that.
01:04:27
Speaker
So those would be acute ketocollamine excess, whether due to feel or cocaine, and then pregnancy are probably the special clinical situations worth mentioning.
01:04:43
Speaker
Let me ask you one zebra that stuck with me and I've never encountered it in clinical practice, but I did encounter it in my medicine boards many, many, many, many years ago.
01:04:53
Speaker
And that's the scleroderma hypertensive crisis.
01:04:58
Speaker
Is IV ACE inhibitors still the drug of choice or is that just something that is long forgotten?
01:05:05
Speaker
No, it is not long forgotten.
01:05:07
Speaker
The treatment of choice, you just, you've got to be gutsy to make the diagnosis, right?
01:05:13
Speaker
The key thing there is making the diagnosis.
01:05:16
Speaker
And the treatment is, because it's the kind of patient who comes in with severe hypertension, acute renal failure, and the drug you go for is exactly the drug that you avoid most of the times.
01:05:28
Speaker
And that's for the rapid reduction of blood pressure, if the patient has, especially if there is extra renal involvement,
01:05:42
Speaker
you will need to use something else that you have greater control.
01:05:46
Speaker
So you will need to use nicardipine.
01:05:49
Speaker
You will need to use maybe the last one I saw, which was many years ago, we actually used nipride.
01:05:55
Speaker
But you need to start an ACE inhibitor at the same time.
01:05:59
Speaker
But it would not be a good idea to use IV enalaprolat as your only drug because you don't have that much control with enalaprolat.
01:06:08
Speaker
And this is someone that if they are taking PO,
01:06:12
Speaker
the drug of choice is actually Captopril because there might be an added advantage of the sulfhydro components of Captopril.
01:06:21
Speaker
So that is something still argued.
01:06:23
Speaker
There's not a ton of data on that.
01:06:25
Speaker
But people with scleroderma renal crisis are usually treated not only with ACE inhibitors, but specifically with Captopril.
01:06:34
Speaker
So the best approach would be to use a drug that you can titrate more carefully for the blood pressure reduction.
01:06:42
Speaker
And then at the very same time, start an ACE inhibitor.
01:06:47
Speaker
And whether you want to use inalaprolat immediately or just throw captopril at them, that in my mind doesn't make as much of a difference.
01:06:55
Speaker
You're using that to treat the renal crisis, but rely on something that's more potent and more easily titratable to treat the blood pressure.
01:07:06
Speaker
Does that make sense?
01:07:08
Speaker
It does.
01:07:10
Speaker
I haven't encountered one of these patients, but it's always nice to review some of these severs that stuck with us from our internal medicine training.
01:07:17
Speaker
But I think this has been a wonderful conversation, although I think there's a lot of obviously of very valid pearls, very actionable items for our clinicians who are listening to the podcast to take to the bedside.
01:07:30
Speaker
And I want to respect your time.
01:07:31
Speaker
I could continue talking about this for a long time, but I know that we want to be respectful of your time.
01:07:36
Speaker
So
01:07:37
Speaker
In closing, what we usually do in the podcast is... Sergio, excuse me.
01:07:42
Speaker
Can I make one comment?
01:07:44
Speaker
We didn't talk about hypertensive urgencies.
01:07:47
Speaker
And the one comment I want to make, because this is something that happens so often in the hospital, and not only in the wards, but also in the step-down units and in the ICUs, is the aggressive treatment of just plain hypertensive urgencies.
01:08:02
Speaker
And that's something that we should avoid altogether.
01:08:05
Speaker
eliminate IV therapy.
01:08:08
Speaker
So people who just because their blood pressure is now 200 over 120, the answer to that is not to give IV hydralazine or IV libitolol or whatever drug you choose.
01:08:18
Speaker
The choice for that is to adjust the long-acting drugs.
01:08:23
Speaker
And if the patient's symptomatic, there's a few and you want to see a little faster control, probably oral clonidine or oral libitolol are your best friends.
01:08:34
Speaker
So stick with those drugs only if you need to control symptoms or you want to calm people up so that people are not too excited for several hours.
01:08:45
Speaker
Adjust the long-acting drugs.
01:08:47
Speaker
Do not use IV drugs because we're going to cause more harm than good by doing that.
01:08:52
Speaker
So I just wanted to make sure that we didn't finish our conversation without that comment.
01:08:58
Speaker
Absolutely, and I'm happy you brought that up because I did have it in my notes, and it is true.
01:09:02
Speaker
one of the most frequent calls that our clinicians get is from a nurse for somebody who has a very elevated blood pressure.
01:09:10
Speaker
And it's almost like the knee jerk reaction is to give them something IV and we're really treating the nurse, but we're at risk of harming the patient.
01:09:17
Speaker
So I think that making that distinction, if there is or no organ damage and in those who are not, I agree with you a hundred percent, Alden, I'm happy that you made that point because I do think that this is a common occurrence in hospitals
01:09:30
Speaker
And then you go and look at the patient and they're asymptomatic, have no acute organ damage, and there's really no need to initiate, I mean, aggressive therapy that could just be harmful.
01:09:39
Speaker
So that's a great point, I mean, in terms of that distinction.
01:09:43
Speaker
Thank you for making that.
01:09:46
Speaker
So as I was saying, in terms of closing, we'd like to finish the podcast by tapping into the wisdom of our guests and asking a couple of questions that are unrelated to the topic that we were discussing clinically.
01:09:56
Speaker
Would that be okay?
01:09:58
Speaker
That would be okay.
01:10:01
Speaker
So the first question relates to books, Aldo, and I was wondering is what books have influenced you the most or what books have you most often gifted to others?
01:10:11
Speaker
So I thought of two books.
01:10:15
Speaker
One that really had a big impact on me about maybe 20 years ago or so is called Blindness by Josรฉ Saramago.
01:10:25
Speaker
He's a Portuguese writer.
01:10:27
Speaker
I'm Brazilian so I speak Portuguese and I could read his work in Portuguese and he was a Nobel Prize winner in Sometime in the 90s for literature and he's a wonderful writer and this book is is a Real interesting story about the development of an it's acute blindness as an epidemic of
01:10:57
Speaker
and how the sudden development of blindness just brings the worst in society and how good people can suddenly be heavily changed by the fears that come along by that.
01:11:18
Speaker
And it's told in a wonderful way.
01:11:22
Speaker
It's really a wonderful book
01:11:26
Speaker
that makes us think about how fragile our stability is.
01:11:31
Speaker
And that's Blindness by Saramago.
01:11:33
Speaker
The second one is really a satire that it's called Portuguese Irregular Verbs, and it has nothing to do with Portuguese, by the way.
01:11:42
Speaker
And Portuguese Irregular Verbs by Alexander McCall Smith, who is a Scottish lawyer, and he's a satirist.
01:11:53
Speaker
And this is a short book, it's about 130 pages.
01:11:57
Speaker
And it's a satire about three professors who are romance, and one of them, the main character is a romance philologist.
01:12:09
Speaker
And it goes into this importance that we give to ourselves for things that are really meaningless.
01:12:18
Speaker
And I see that in academia very often.
01:12:21
Speaker
We think we are really relevant people.
01:12:25
Speaker
And obviously there are many of us who are.
01:12:29
Speaker
There are many people who are Nobel laureates and who have really changed the way life as it is.
01:12:38
Speaker
But there are so many of us who we are good people and we go through life.
01:12:45
Speaker
But sometimes we get so caught up in the little worlds that we live in and we lose sight of how, you know, there are so many more important things in life than that little world and that little expertise.
01:13:01
Speaker
And it's a wonderful read and it's so funny.
01:13:04
Speaker
I think it's a really worthwhile read.
01:13:07
Speaker
And I just don't gift it to my friends.
01:13:10
Speaker
because I don't want them to think that I think their work is irrelevant.
01:13:14
Speaker
You're giving them a message.
01:13:17
Speaker
So I definitely have not read that book, and I will look it up.
01:13:20
Speaker
Blindness, obviously, is a classic.
01:13:22
Speaker
And like you mentioned, Saramago is a Nobel laureate.
01:13:25
Speaker
But I think it also speaks, obviously, blindness.
01:13:28
Speaker
I mean, a way of looking at it is that we all have blind spots and that these blind spots also sometimes bring the worst out of us.
01:13:36
Speaker
And that I think that obviously he does it in a beautiful narrative.
01:13:39
Speaker
And I think both we will link to the show notes.
01:13:43
Speaker
And I will definitely look for Portuguese irregular verbs.
01:13:46
Speaker
I'm intrigued now, but I do like... It's a funny, interesting read.
01:13:52
Speaker
Absolutely.
01:13:53
Speaker
I love that.
01:13:54
Speaker
So the second question, Aldo, has to do with something you believe to be true in medicine or in life that most other people don't believe to be true or act as if it's not true.
01:14:05
Speaker
So I'm going to tell you one in medicine.
01:14:06
Speaker
And I don't know that most people believe it or not.
01:14:11
Speaker
I'll tell you that I believe, even though I can't explain, is that I think that patients often, that there is such a thing as death by giving up or letting go.
01:14:23
Speaker
In other words, a patient who has no reason to die, no reason to die today, but many reasons to die in a week or two,
01:14:33
Speaker
And you come by, you have a discussion about an end of life.
01:14:36
Speaker
We're going to withhold dialysis.
01:14:38
Speaker
We're going to withdraw dialysis.
01:14:40
Speaker
Obviously, that's the world I live in.
01:14:43
Speaker
But, you know, everything else is stable.
01:14:45
Speaker
The potassium is fine.
01:14:47
Speaker
The acid-base balance is fine.
01:14:49
Speaker
There's absolutely no reason for the patient to die.
01:14:52
Speaker
And we have that discussion at 4 o'clock in the afternoon.
01:14:55
Speaker
And I come by to round the next morning and the patient died.
01:14:59
Speaker
I cannot count how many times I've seen this.
01:15:02
Speaker
And so...
01:15:03
Speaker
this belief I do have that there's something that keeps you holding on to life and that letting go brings death more promptly for reasons that I cannot explain as a fairly intelligent physician.
01:15:24
Speaker
And it's very interesting, Aldo.
01:15:25
Speaker
I mean, obviously, in the world of the ICU, you always assume that you go from one extreme to the other.
01:15:31
Speaker
It's like a pendulum, right?
01:15:33
Speaker
And on one hand, obviously, there are patients in whom these discussions of goals of care are very appropriate, very meaningful.
01:15:40
Speaker
But as you move forward, I think studies have shown in different contexts, they haven't explained the reason, but this whole idea of a self-fulfilling prophecy.
01:15:50
Speaker
The more you talk to people about not doing this, not doing that, the more people die or the rapidly they die.
01:15:56
Speaker
And it might be touching on one of the observations that you make, and it might be something inherently
01:16:04
Speaker
in the patient that also, I mean, drives or helps accelerate that, which I think is obviously very, very interesting.
01:16:11
Speaker
But I think that that's a very interesting point.
01:16:14
Speaker
And I think it's something that I always grapple with because you go almost from one extreme to the other and really trying to find the balance is, I think, one of the big challenges in medicine and in life in general.
01:16:26
Speaker
So my last question is, what would you want every listener to the podcast to know?
01:16:32
Speaker
Could be a quote of fact.
01:16:33
Speaker
Yeah.
01:16:35
Speaker
So that is most know.
01:16:40
Speaker
Sometimes they forget.
01:16:42
Speaker
I think it's a very important one.
01:16:45
Speaker
There is no intelligent discussion about acid-base balance without a blood gas.
01:16:52
Speaker
So why am I bringing that up?
01:16:54
Speaker
Because periodically I get asked to comment, hey, Aldo, can you come by and comment on this urine and ion gap
01:17:02
Speaker
for this patient.
01:17:03
Speaker
And what's the type of RTA with this urine and ion gap result and the bicarbonate of 16?
01:17:10
Speaker
And I asked for the blood gases and we don't have it.
01:17:13
Speaker
And it's a patient with a pH of whatever, 747 because of a respiratory elk.
01:17:19
Speaker
So I cannot count how often I see this still coming from intensive care physicians.
01:17:27
Speaker
So whenever you want to discuss acid-base, I love talking about acid-base balance, but we can never have an intelligent discussion without blood gases.
01:17:38
Speaker
I love it.
01:17:38
Speaker
And I think it's a great point.
01:17:40
Speaker
Perfect place to stop.
01:17:41
Speaker
And maybe we'll have you back to talk about acid-base, and I'll have a blood gas if we do that.
01:17:48
Speaker
That's great.
01:17:49
Speaker
It was a pleasure talking to you, Serge.
01:17:51
Speaker
Thank you so much for your time, Aldo.
01:17:53
Speaker
I really appreciate it.
01:17:54
Speaker
And I sincerely hope to have you back on the podcast soon.
01:17:58
Speaker
You bet.
01:17:58
Speaker
You have a good day.
01:18:01
Speaker
Thank you for listening to Critical Matters, a sound critical care podcast.
01:18:05
Speaker
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01:18:11
Speaker
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01:18:16
Speaker
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