1. 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

2. Case Studies of Acute Hypertension
Case Study #1
Type A Aortic Dissection

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

4. 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

5. 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

6. Case Study 1: Type A Aortic Dissection
12.3
<
>
<
Chem:
Heme:
ECG: no ischemic changes
CT: TEE:
110
LFTs Coags
WNL WNL 39

7. Case Study 1: Type A Aortic Dissection
Diagnosis
Type A Aortic Dissection
w/severe aortic insufficiency
Management
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)

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

9. Case Study 1: Type A Aortic Dissection
In the OR

10. Case Study 1: Type A Aortic Dissection
In the OR

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

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

13. 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

14. 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)

15. 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.

16. Case Studies of Acute Hypertension
Case Study #2
Acute Coronary Syndrome

17. 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

18. 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 18

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

20. 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
STEMI + Hypertensive Emergency 20

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

22. 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

23. 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

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

25. 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

26. 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

27. Case Study 3: Aortic Valve Replacement
<
>
14.1
<
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
LFTs Coags
WNL WNL
41.2

28. 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

29. Case Study 3: Aortic Valve Replacement
In the OR

30. Case Study 3: Aortic Valve Replacement
In the OR

31. 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

32. 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