Watch here tomorrow for the launch of a new accredited tweetorial on #hypertension management in #AorticDissection! Earn 0.5 CE/CME credits: physicians, nurses, pharmacists! Expert faculty @JerroldLevy. #medtwitter @academiccme @MedTweetorials @ACEPNow @ENAorg @CCPharmacists
1) Welcome to a tweetorial on #hypertension management in #AorticDissection! Accredited for 0.50 CE/CME credits by @academiccme: physicians, nurses, pharmacists! Expert faculty @JerroldLevy. Hello @DocAnitaGupta, @LorraineC_MD, @WarnerMatthewA, @DrManiCTSurgery, @PatrickGoldste4 
2) . . . Supported by educational grant funding from Abbott, AstraZeneca, Bayer, Chiesi, NovoNordisk. Follow this thread for credit. And here is a case . . .
3) 58F, 87kg, presents to ED with sudden sharp chest pain radiating to back. PMH: HTN with poor compliance. Initial BP 230/110 R arm, 220/100 L arm. HR 110s. O2 sat 94%. ECG: ST, LVH with strain. CXR:
4) Widened mediastinum noted, not present on CXR 2 years ago. Labs: Creat 2.8. H/H 14/41. INR 1.1. D-dimer 3300 ng/ml. Pt taken to ICU, line placed, plan chest CT when BP controlled. Patient states pain excruciating and associated with sense of foreboding.
5) Acute aortic dissection suspected. CVP and art lines placed. Careful neuro exam reveals no deficits. L radial pulse diminished compared with R.
6) BTW, take note of that increased #Ddimer. D-dimer is often used to evaluate suspected #AorticDissection and can be useful in initial patient assessment. See nature.com/articles/srep2…
7) Lots to unpack re #AorticDissection (incidence 2.6-3.5/100,000 person years, 2/3 males), but let's focus on acute BP management.
8) The goal is "anti-impulse" tx, aimed at reducing the pressure exerted with each heartbeat on the dissecting intimal flap. Anti-impulse means reducing pain (sympathetic tone) + reducing HR and BP--together, the "pulse-pressure product."
9) Morphine is the usual parenteral analgesic of choice. It is anxiolytic, may slightly dampen BP but without causing reflex tachycardia, and can be titrated carefully. If ACS is a differential dx, sometimes we are confused because NTG may provide some analgesia.
10) Antihypertensive therapy can be trickier still. For initial treatment, IV beta-blockers make the most sense, as they lower aortic wall stress by controlling velocity, rate of ventricular contraction, and BP. Esmolol can be titrated as a continuous infusion, but . . .
11) . . . most patients will require additional anti-hypertensive therapy to reach SBP goal of < 120mm Hg. Also, some patients can't tolerate beta-blockade. Back-up and secondary options include CCBs, nitroprusside, or IV ACEi.
12) In addition to (or instead of) IV beta blockers, what did you use in your last #AorticDissection case?
13) Indicate your answer and please return tomorrow for poll results and further discussion. Shout-outs to @ProfHinkelbein @Ajar_Kochar @ogi_gajic @alimkakeng @DukeCTSurgery @ChrisTroianos
14) Welcome back to our accredited tweetorial on BP management in #AorticDissection. I am @JerroldLevy. Check out the poll results. All of these options could have been suitable for your patient, though NTP or clevidipine probably would be most commonly used.
15) We all know #nitroprusside. It is of course a fast-acting and generally reliable vasodilator. It should not be used before you have the arterial line in. It should NOT be used in our patient without a beta-blocker already on board to protect against reflex tachycardia.
16) It is increasingly expensive, clumsy to use (think foil-wraps to the tubing), decreases venous return, and should not be used in patients with poor cerebral or poor coronary perfusion--issues not uncommon in the patient with #AorticDissection.
17) Another issue with #nitroprusside is potential toxicity of its metabolites. It is initially metabolized to cyanide, which is then metabolized in the liver to thiocyanate, which is then cleared by the kidneys . . .
18) Hepatic or renal impairment--again not uncommon comorbidities in #AorticDissection--or long-term infusion of NTP, might lead to accumulation of these toxic metabolites.
19) In the two cohort studies of nicardipine in the treatment of hypertensive emergency in acute #AorticDissection, it was reported that the drug has a rapid and beneficial effect on decreasing BP (Kyobu Geka - Japanese J Thorac Surg 1995;48:290-4; J Int Med Res 2002;30:337-45
20) #Clevidipine, like #nifedipine and #nicardipine, is a dihydropyridine that acts as an L-type calcium channel blocker. It is given only as a continuous IV infusion in a lipid emulsion. Pertinent to use as an antihypertensive in #AorticDissection, it is easily titratable.
21) It is ultrashort acting with rapid onset and offset of effect. Importantly for predictability of effect, clevidipine reduces BP by decreasing arteriolar resistance without affecting venous capacitance vessels.
22) In ESCAPE-1 (Anesth Analg 2007;105:918–25) and ESCAPE-2 (Anesth Analg 2008;107:59–67), clevidipine effectively treated perioperative HTN in cardiac surgery patients.
23) In the ECLIPSE trials (Anesth Analg. 2008;107:1110–21), clevidipine was more effective than NTG or NTP and was similar to nicardipine for keeping SBP within target range.
24) While they have similar rapid onset of action, clevidipine has a much briefer duration of action, lasting mins compared to 3h with nicardipine . . . so clevidipine can be more easily titrated (J Stroke Cerebrovasc Dis 2018 doi:10.1016/j.jstrokecerebrovasdis.2018.03.001).
25) Finally, in an ED population managed largely without invasive BP monitoring, clevidipine was safe and effective in managing hypertensive emergencies of varying etiology. See VELOCITY led by @md_pollack, Ann Emerg Med. 2008;53:329-38.
26) Return tomorrow for a case wrap-up and for your free #CME/CE! Props to @AlexAndersonMD @banfi_carlo @DrDePasquale @MaryCushmanMD @texhern @ankeetudani @JonSAndrewsMD @CochraneHTN @JEscaned
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