Case Studies in Acute Hypertension Investigations ● Advances ● Applications Case Studies in Acute Hypertension Edwin G. Avery, MD, CPI Assistant Professor of Anesthesiology Massachusetts General Hospital Heart Center Harvard Medical School

Case Studies of Acute Hypertension Case Study #1 Type A Aortic Dissection www.radpod.org

Case Studies of Acute Hypertension Case Study #1 Acknowledgement Thank you to Dr. Michael England for sharing this interesting case

Case Study 1: Type A Aortic Dissection 44-year-old female presents for surgical correction of a Type A dissection HPI: presented to ED complaining of sudden onset of severe chest pain and shortness of breath. PHM/PSH: obesity Allergies: NKDA Medications: none Fam Hx: noncontributory ROS: unremarkable www.edpma.com

Case Study 1: Type A Aortic Dissection General: anxious, grossly obese. Ht: 62 inches Wt: 102 kg VS: 141/45 (R=L); HR 80’s reg; Resp 18; SpO2 96% RA Neuro: alert & oriented x3; no gross deficits Pulmonary: B/L rales Cardiac: S1S2 reg, grade IV syst. murmur Extrem: 2+ palpable B/L UE & LE; no edema turbosquid.com

Case Study 1: Type A Aortic Dissection 12.3 < > < 112 20 4.0 24 1.2 Chem: Heme: ECG: no ischemic changes CT: TEE: 110 10 250 LFTs Coags WNL WNL 39

Case Study 1: Type A Aortic Dissection Diagnosis Type A Aortic Dissection w/severe aortic insufficiency Management www.radiologyassistant.nl Immediate β-blockade Control SBP with IV antihypertensive to prevent aortic rupture & further extension of dissection Proceed to the OR for immediate surgical correction (ascending aortic replacement, +/- AVR)

Case Study 1: Type A Aortic Dissection Management β-blockade: reduces dP/dt IV antihypertensive: reduces shear forces on the weakened aortic wall Surgical correction: reduces observed Type A dissection mortality (~↑2% per hour). Uncorrected in-hospital mortality (58%) vs. surgically corrected (27.4%)1. www.radiologyassistant.nl Hagan et al. Jama 2000;283:897

Case Study 1: Type A Aortic Dissection In the OR

Case Study 1: Type A Aortic Dissection In the OR

Case Study 1: Type A Aortic Dissection In the OR CPB Induction Incision

Case Study 1: Type A Aortic Dissection In the OR – “The Zone” CPB Induction Incision 120 95

Case Study 1: Type A Aortic Dissection In the OR – the drugs NTG nitroglycerin CPB Induction Incision SNP sodium nitroprusside CLV clevidipine NTG SNP CLV

Case Study 1: Type A Aortic Dissection In the OR – the drugs NTG nitroglycerin CPB Induction Incision SNP sodium nitroprusside CLV clevidipine NTG SNP CLV 10 2 4 6 8 Clevidipine dose adjustment (mg/hr)

Case Study 1: Type A Aortic Dissection Summary The ultra-short acting dihydropyridine calcium channel blocker, clevidipine, can be used to safely and effectively manage the acute hypertension that accompanies one of the most morbid and potentially mortal disorders of the cardiovascular system.

Case Studies of Acute Hypertension Case Study #2 Acute Coronary Syndrome http://library.med.utah.edu

Case Studies of Acute Hypertension Case Study #2 Acknowledgement Thank you to Dr. Charles Pollack at the University of Pennsylvania for sharing this interesting case

Case Study #2: Acute Coronary Syndrome 58 y/o male presents to ED with chest pain of acute onset radiating to left jaw and shoulder, accompanied by SOB Triage vital signs were pulse 92/min, resp 24/min, and BP 212/126 mm Hg PMH included known CAD, CHF, and hyperlipidemia ECG performed in Triage http://mykentuckyheart.com 18

Case Study #2: Acute Coronary Syndrome Acute Anterior STE Myocardial Infarction 19

STEMI + Hypertensive Emergency Case Study #2: Acute Coronary Syndrome Physical examination: symmetrical bounding pulses, diaphoresis, and rales in both lung bases Management: ASA 325 mg Clopidogrel 600 mg Unfractionated heparin by IV infusion Nitroglycerin by IV infusion Beta-blockers are held because of concern over heart failure Prior to cath lab transfer: recheck BP is 196/118; and patient is diagnosed with www.etopiamedia.net STEMI + Hypertensive Emergency 20

Case Study #2: Acute Coronary Syndrome Hemodynamic Control 170 160 21

Case Study #2: Acute Coronary Syndrome Hemodynamic Control 12 196 10 192 188 176 168 8 166 162 162 Clevidipine (mg/hr) 6 4 2 22

Case Study #2: Acute Coronary Syndrome Summary Clevidipine can be used safely and effectively to care for a patient with an acute coronary syndrome using a peripheral IV and a blood pressure cuff. There was no evidence of coronary steal or worsening of this patient’s chest pain. Target BP control was obtained in less than 10 minutes. 23

Aortic Valve Replacement Case Studies of Acute Hypertension Case Study #3 Aortic Valve Replacement

Case Study 3: Aortic Valve Replacement 78-year-old male presents for aortic valve replacement HPI: presented with symptoms of shortness of breath and DOE. PHM/PSH: AS, MI, CAD (stents x2), HTN (brittle), Chol, TIAs secondary to spontaneous cholesterol emboli Allergies: NKDA Medications: metoprolol Fam Hx: noncontributory ROS: as per HPI o/w unremarkable

Case Study 3: Aortic Valve Replacement General: fatigued appearing Ht: 72 inches Wt: 90 kg VS: 128/62 (R=L); HR 60’s reg; Resp 18; SpO2 98% RA Neuro: alert & oriented x3; no gross deficits Pulmonary: CTA bilaterally Cardiac: S1S2 reg, grade IV syst. murmur Extrem: 2+ palpable B/L UE & LE; no edema

Case Study 3: Aortic Valve Replacement < > 14.1 < 139 103 25 4.5 24 1.3 Chem: Heme: ECG: no ischemic changes TEE: Aortic stenosis (AVA 0.7 cm2), gradient (P 51/M 32 mmHg w/CI 2.9 L/min/m2) 91 6.8 172 LFTs Coags WNL WNL 41.2

Case Study 3: Aortic Valve Replacement Diagnosis Severe Aortic Stenosis with left ventricular hypertrophy Management Surgical aortic valve replacement with a bioprosthesis Control heart rate, maintain NSR, manage SBP with an IV antihypertensive to prevent LV wall stress and MVO2, avoid hypotensive overshoots

Case Study 3: Aortic Valve Replacement In the OR

Case Study 3: Aortic Valve Replacement In the OR

Case Study 3: Aortic Valve Replacement In the OR - The Zone Induction CPB F F 2 4 8 16 2 2 4 Clevidipine (mg/hr) F - Fentanyl bolus

Case Study 3: Aortic Valve Replacement Summary Clevidipine can be used safely and effectively to provide hemodynamic support for patients with complex cardiovascular disease profiles (i.e. need to strictly ovoid overshoot hypotension [AS] & reflex tachycardia [AS, LVH, CAD]). Target BP control was expeditiously obtained and maintained in this patient. 32