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Newman C, Petruzzi V, Ramirez PT, Hobday C. Hypertensive Disorders of Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:4-12. [PMID: 38495660 PMCID: PMC10941709 DOI: 10.14797/mdcvj.1305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 03/19/2024] Open
Abstract
According to the American College of Obstetricians and Gynecologists (ACOG), women who have a systolic blood pressure ≥ 140 mm Hg and/or a diastolic pressure ≥ 90 mm Hg before pregnancy or before 20 weeks of gestation have chronic hypertension. Up to 1.5% of women in their childbearing years have a diagnosis of chronic hypertension, and 16% of pregnant women develop hypertension during their pregnancy. Physiological cardiovascular changes from pregnancy may mask or exacerbate hypertensive diseases during gestation, which is why prepregnancy counseling is emphasized for all patients to optimize comorbidities and establish a patient's baseline blood pressure. This review provides an overview of the diagnoses and treatments of hypertensive diseases that can occur in pregnancy, including definitions of key terms and types of hypertension as well as ACOG recommendations.
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Affiliation(s)
- Courtney Newman
- Obstetrics and Gynecology Department, Houston Methodist, Houston, Texas, US
| | - Victoria Petruzzi
- Obstetrics and Gynecology Department, Houston Methodist, Houston, Texas, US
| | - Pedro T. Ramirez
- Obstetrics and Gynecology Department, Gynecological Oncology Department, Houston Methodist, Houston, Texas, US
| | - Christopher Hobday
- Obstetrics and Gynecology Department, Houston Methodist, Houston, Texas, US
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Acute blood pressure elevation: Therapeutic approach. Pharmacol Res 2018; 130:180-190. [DOI: 10.1016/j.phrs.2018.02.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/21/2017] [Accepted: 02/21/2018] [Indexed: 12/25/2022]
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Yang WC, Lin MJ, Chen CY, Wu HP. Clinical overview of hypertensive crisis in children. World J Clin Cases 2015; 3:510-513. [PMID: 26090371 PMCID: PMC4468897 DOI: 10.12998/wjcc.v3.i6.510] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 02/15/2015] [Accepted: 03/16/2015] [Indexed: 02/05/2023] Open
Abstract
Hypertensive emergencies and hypertensive urgencies in children are uncommonly encountered in the pediatric emergency department and intensive care units, but the diseases are potentially a life-threatening medical emergency. In comparison with adults, hypertension in children is mostly asymptomatic and most have no history of hypertension. Additionally, measuring accurate blood pressure values in younger children is not easy. This article reviews current concepts in pediatric patients with severe hypertension.
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Muiesan ML, Salvetti M, Amadoro V, di Somma S, Perlini S, Semplicini A, Borghi C, Volpe M, Saba PS, Cameli M, Ciccone MM, Maiello M, Modesti PA, Novo S, Palmiero P, Scicchitano P, Rosei EA, Pedrinelli R. An update on hypertensive emergencies and urgencies. J Cardiovasc Med (Hagerstown) 2015; 16:372-382. [PMID: 25575271 DOI: 10.2459/jcm.0000000000000223] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Severe acute arterial hypertension is usually defined as 'hypertensive crisis', although 'hypertensive emergencies' or 'hypertensive urgencies', as suggested by the Joint National Committee and the European Society of Hypertension, have completely different diagnostic and therapeutic approaches.The prevalence and demographics of hypertensive emergencies and urgencies have changed over the last four decades, but hypertensive emergencies and urgencies are still associated with significant morbidity and mortality.Different scientific societies have repeatedly produced up-to-date guidelines; however, the treatment of hypertensive emergencies and urgencies is still inappropriate, with potential clinical implications.This review focuses on hypertensive emergencies and urgencies management and treatment, as suggested by recent data.
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Affiliation(s)
- Maria Lorenza Muiesan
- aDepartment of Clinical and Experimental Sciences University of Brescia, 25100 Spedali Civili, Brescia bDepartment of Medical-Surgery Sciences and Translational Medicine, Emergency Department, University La Sapienza, Sant'Andrea Hospital Rome, Rome cDepartment of Internal Medicine and Therapeutics, University of Pavia, Lombardy dDepartment of Internal Medicine 1, USL12 Veneziana, Venice eDepartment of Medicine, University of Padua, Padova fDepartment of ScienzeMediche e Chirurgiche, S.Orsola-Malpighi University Hospital, Bologna gDivision of Cardiology, Department of Medicina Clinica e Molecolare, University Roma 'Sapienza' - Azienda Ospedaliera Sant'Andrea, and IRCCS Neuromed, Rome hDivision of Cardiology, AOU Sassari, Sassari iDepartment of Cardiovascular Diseases, University of Siena, Tuscany jCardiovascular Disease Section, Department of Emergency and Organ Tranplantation, University of Bari, Bari kAS Department of Cardiology, Brindisi District, Brindisi lDepartment of Clinical and Experimental Medicine, University of Florence, Florence mDepartment of Internal Medicine and Cardiovascular Diseases, University of Palermo, Palermo nDipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Pisa, Italy
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Abstract
PURPOSE OF REVIEW Systemic hypertension (HTN) is a common medical condition affecting over 1 billion people worldwide. One to two percent of patients with HTN develop acute elevations of blood pressure (hypertensive crises) that require medical treatment. However, only patients with true hypertensive emergencies require the immediate and controlled reduction of blood pressure with an intravenous antihypertensive agent. RECENT FINDINGS Although the mortality from hypertensive emergencies has decreased, the prevalence and demographics of this disorder have not changed over the last 4 decades. Clinical experience and reported data suggest that patients with hypertensive urgencies are frequently inappropriately treated with intravenous antihypertensive agents, whereas patients with true hypertensive emergencies are overtreated with significant complications. SUMMARY Despite published guidelines, most patients with hypertensive crises are poorly managed with potentially severe outcomes.
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McCoy S, Baldwin K. Pharmacotherapeutic options for the treatment of preeclampsia. Am J Health Syst Pharm 2009; 66:337-44. [PMID: 19202042 DOI: 10.2146/ajhp080104] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pharmacotherapeutic options for the treatment of preeclampsia are reviewed. SUMMARY Risk factors for the development of preeclampsia include microvascular diseases, such as diabetes mellitus; vascular and connective tissue disorders; hypertension; antiphospholipid antibody syndrome; and nephropathy. Several pathophysiological factors contribute to the development of the preeclamptic state, including vasospasm onset, coagulation system activation, increased inflammatory response, and ischemia. The specific agents used for the treatment of preeclampsia are dependent on a number of factors including symptom severity, maternal or fetal compromise, the progression to eclampsia, gestational period, and cervical status. The diagnosis of preeclampsia beyond the gestation period of 38 weeks requires delivery. The presence of maternal compromise or eclampsia at gestation greater than 20 weeks also necessitates delivery. In cases of chronic or mild hypertension, oral methyldopa may be administered on an outpatient basis. Intravenous hydralazine is a commonly administered arteriolar vasodilator that is effective for hypertensive emergencies associated with pregnancies. The most common adverse effect of hydralazine administration is unpredictable hypotension. Labetalol decreases heart rate and may be preferred because of a lack of reflex tachycardia, hypotension, or increased intracranial pressure. However, the drug of choice for the prevention and control of maternal seizures in patients with severe preeclampsia or eclampsia during the peripartum period is i.v. magnesium sulfate. Therapeutic serum magnesium levels cause cerebral vasodilation, thereby reversing the ischemia produced by cerebral vasospasm during an eclamptic episode. The results of one study indicated that women receiving magnesium sulfate therapy had a 58% lower risk of eclampsia than placebo. CONCLUSION Magnesium sulfate remains the drug of choice for the prevention and treatment of preeclampsia. Alternative antihypertensive agents may provide additional benefit in the management of hypertension for preeclamptic patients.
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Affiliation(s)
- Stacey McCoy
- Baptist Medical Center and Wolfson Children's Hospital, Jacksonville, FL 32207, USA.
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Abstract
Approximately 72 million people in the US experience hypertension. Worldwide, hypertension may affect as many as 1 billion people and be responsible for approximately 7.1 million deaths per year. It is estimated that approximately 1% of patients with hypertension will, at some point, develop a hypertensive crisis. Hypertensive crises are further defined as either hypertensive emergencies or urgencies, depending on the degree of blood pressure elevation and presence of end-organ damage. Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e. hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent, while severe hypertension without acute end-organ damage (i.e. hypertensive urgency) is usually treated with oral antihypertensive agents. The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure. The appropriate therapeutic approach of each patient will depend on their clinical presentation. Patients with hypertensive emergencies are best treated in an intensive care unit with titratable, intravenous, hypotensive agents. Rapid-acting intravenous antihypertensive agents are available, including labetalol, esmolol, fenoldopam, nicardipine and sodium nitroprusside. Newer agents, such as clevidipine and fenoldopam, may hold considerable advantages to other available agents in the management of hypertensive crises. Sodium nitroprusside is an extremely toxic drug and its use in the treatment of hypertensive emergencies should be avoided. Similarly, nifedipine, nitroglycerin and hydralazine should not to be considered first-line therapies in the management of hypertensive crises because these agents are associated with significant toxicities and/or adverse effects.
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Affiliation(s)
- Joseph Varon
- The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Abstract
The appropriate and timely evaluation and treatment of patients with severely elevated blood pressure is essential to avoid serious adverse outcomes. Most importantly, the distinction between a hypertensive emergency (crisis) and urgency needs to be made. A sudden elevation in systolic (SBP) and/or diastolic blood pressure (DBP) that is associated with acute end organ damage (cardiovascular, cerebrovascular, or renal) is defined as a hypertensive crisis or emergency. In contrast, acute elevation in SBP and/or DBP not associated with evidence of end organ damage is defined as hypertensive urgency. In patients with a hypertensive emergency, blood pressure control should be attained as expeditiously as possible with parenteral medications to prevent ongoing and potentially permanent end organ damage. In contrast, with hypertensive urgency, blood pressure control can be achieved with the use of oral medications within 24-48 hours. This paper reviews the management of hypertensive emergencies.
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Affiliation(s)
- Andrew R Haas
- Division of Critical Care, Pulmonary, Allergy and Immunologic Disease, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Abstract
OBJECTIVE Obstetrical hypertensive emergencies are life-threatening conditions involving significant risk to both the mother and fetus. Aggressive treatment of the maternal hypertensive state requires an initial consideration of the effect of treatment on the fetus, via changes to the uteroplacental circulation with treatment. The challenge then is to correct blood pressure using appropriate, safe pharmacologic agents to prevent catastrophic maternal consequences, while minimizing acute changes to placental perfusion and any corresponding fetal ill effects. Hypertension in pregnancy may be one manifestation of a multiple-system pathologic process, as is the case in preeclampsia. Blood pressure control, along with delivery, will be the first step in treating the renal, hematologic, hepatic, and cardiac dysfunction that can be seen in preeclampsia. DESIGN A review of medications most commonly used for hypertensive emergencies in pregnancy. CONCLUSIONS Hypertensive emergencies in pregnancy require prompt evaluation and treatment in an intensive care setting to prevent untoward effects to both the fetus and mother.
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Affiliation(s)
- Alex C Vidaeff
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Texas Health Science Center-Houston, Houston, TX, USA
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Abstract
Hypertension is an extremely common clinical problem, affecting approximately 50 million people in the USA and approximately 1 billion individuals worldwide. Approximately 1% of these patients will develop acute elevations in blood pressure at some point in their lifetime. A number of terms have been applied to severe hypertension, including hypertensive crises, emergencies, and urgencies. By definition, acute elevations in blood pressure that are associated with end-organ damage are called hypertensive crises. Immediate reduction in blood pressure is required only in patients with acute end-organ damage. This article reviews current concepts, and common misconceptions and pitfalls in the diagnosis and management of patients with acutely elevated blood pressure.
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Affiliation(s)
- Joseph Varon
- Associate Professor of Medicine, Pulmonary and Critical Care Section, Baylor College of Medicine, Clinical Associate Professor, The University of Texas Health Science Center, Houston, Texas, USA
| | - Paul E Marik
- Professor of Critical Care and Medicine, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Rosenow DJ, Russell E. Current concepts in the management of hypertensive crisis: emergencies and urgencies. Holist Nurs Pract 2001; 15:12-21. [PMID: 12120491 DOI: 10.1097/00004650-200107000-00005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertensive emergencies and hypertensive urgencies represent a large percentage of major medical emergencies and have the potential of producing serious organ damage or death if not treated promptly and selectively. Several classifications of antihypertensive agents are discussed, with emphasis on selecting agents appropriate for patients' hypertension manifestations and comorbid situations. Epidemiology and evaluation of hypertension, as well as common pharmacokinetics of several common and new oral and parenteral antihypertensive agents, are described. Special nursing considerations of medication administration and gerontology concepts are included.
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Affiliation(s)
- D J Rosenow
- Texas A&M International University, Dr. F.M. Canseco School of Nursing, Laredo, TX, USA
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Abstract
Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.
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Affiliation(s)
- J Varon
- Department of Medicine, Baylor College of Medicine, Houston TX, USA.
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Abstract
Hypertensive encephalopathy is a rare complication of severe or malignant hypertension. When treated promptly it is potentially reversible without leaving long-term neurologic damage. It can be difficult to differentiate from cerebrovascular accidents or uremia. Acute elevations of intracranial pressure cause acute elevations of blood pressure--the Cushing reflex. This association is less clear for chronic elevations of intracranial pressure, which could occur with tumors. In patients with hypertensive encephalopathy, there are usually diffuse neurologic signs, evidence of visual upset, variable alterations in conscious level, and often a history of rather gradual onset and more systemic symptoms beforehand. The optic fundi show the characteristic hemorrhages, exudates and papilledema, while the urine usually contains protein red cells and casts. Early treatment is mandatory but need not be by the parenteral route, and any blood pressure reduction should be gradual. Vigorous antihypertensive therapy under such circumstances can lead to problems with relative hypotension and underperfusion of vital organs such as the brain, the heart and the kidneys.
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Affiliation(s)
- J V Jones
- Department of Cardiology, Royal Infirmary, Bristol, United Kingdom
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Nimmo GR, Lawson AA. Parenteral chlorpromazine and frusemide: safe and effective treatment for hypertensive emergencies. Curr Med Res Opin 1986; 10:203-8. [PMID: 3731825 DOI: 10.1185/03007998609110439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertensive emergencies present a difficult problem of management. Although many treatment regimens have been described over the years, their application has presented problems of adverse effects and all have required detailed and intensive supervision of patients. After favourable results obtained in a preliminary study using a combination of parenteral chlorpromazine and frusemide, a 5-year prospective study was conducted using this treatment to produce rapid reduction in blood pressure in patients with acute onset severe hypertension (blood pressure greater than 225/130 mmHg). The patients involved covered a wide range from 22 to 74 years (mean 47 years) and, on subsequent or previous investigation, were all considered to have essential hypertension. Twenty-seven patients were treated successfully with a single administration of the regimen. Two women required a second treatment before adequate control of blood pressure was achieved and 1 man died of extensive dissecting abdominal aortic aneurysm before the effects of the therapy could be fully assessed. The reduction in blood pressure was gradual but progressive over 4 hours and the pattern of response was uniform. No significant adverse effects related to the treatment were found. Only basic measurement of pulse and blood pressure was considered necessary and so this regimen of therapy is suitable for general use even when sophisticated monitoring facilities are not available and staff levels are limited.
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