Hypertensive emergency secondary to atropine / Emergencia hipertensiva secundaria a atropina

Atropine, a competitive antagonist of acetylcholine muscarinic receptors, is commonly used to treat severe bradycardia by blocking parasympathetic activity. We present a rare case of hypertensive emergency following atropine administration, with only one previous report in the literature. A 78-year-old woman with essential hypertension and hypercholesterolemia was admitted to the cardiac intensive care unit for non-ST segment elevation myocardial infarction. During coronary angiography, an occlusion of the right coronary artery was identified. While removing the diagnostic catheter through the right radial artery, the patient experienced intense pain and discomfort, accompanied by a vasovagal reflex characterized by bradycardia and hypotension. Intravenous atropine (0.5mg) was administered, leading to a rapid rise in heart rate with frequent ventricular ectopy. Subsequently, a progressive and exaggerated elevation in arterial blood pressure occurred, peaking at 294/121mmHg approximately 10min after atropine administration. The patient developed hypertensive acute pulmonary edema, successfully treated with intravenous nitroglycerine (10mg) and furosemide (60mg). Blood pressure normalized after approximately 14min. The exact mechanism of atropine-induced hypertensive emergency remains unknown. While hypertensive emergencies with atropine are exceedingly rare, healthcare professionals should be aware of this potential effect and be prepared for prompt intervention.(AU)

La atropina, un antagonista competitivo de los receptores muscarínicos de acetilcolina, se utiliza comúnmente para tratar la bradicardia severa al bloquear la actividad parasimpática. Presentamos un caso raro de emergencia hipertensiva después de la administración de atropina, con solo un informe previo en la literatura. Una mujer de 78 años con hipertensión esencial e hipercolesterolemia fue ingresada en la unidad de cuidados intensivos cardíacos por infarto agudo de miocardio sin elevación del segmento ST. Durante la angiografía coronaria, se identificó una oclusión de la arteria coronaria derecha. Mientras se retiraba el catéter diagnóstico a través de la arteria radial derecha, la paciente experimentó un intenso dolor y malestar, acompañado de un reflejo vasovagal caracterizado por bradicardia e hipotensión. Se administró atropina intravenosa (0,5 mg), lo que provocó un rápido aumento de la frecuencia cardíaca con frecuente ectopia ventricular. Posteriormente, ocurrió una elevación progresiva y exagerada de la presión arterial, alcanzando un máximo de 294/121 mmHg aproximadamente 10 minutos después de la administración de atropina. La paciente desarrolló edema pulmonar agudo hipertensivo, tratado con éxito con nitroglicerina intravenosa (10 mg) y furosemida (60 mg). La presión arterial se normalizó después de aproximadamente 14 minutos. El mecanismo exacto de la emergencia hipertensiva inducida por atropina sigue siendo desconocido. Aunque las emergencias hipertensivas con atropina son excepcionalmente raras, los profesionales de la salud deben estar al tanto de este efecto potencial y estar preparados para intervenir rápidamente.(AU)

Hypertensive emergency secondary to atropine.

Atropine, a competitive antagonist of acetylcholine muscarinic receptors, is commonly used to treat severe bradycardia by blocking parasympathetic activity. We present a rare case of hypertensive emergency following atropine administration, with only one previous report in the literature. A 78-year-old woman with essential hypertension and hypercholesterolemia was admitted to the cardiac intensive care unit for non-ST segment elevation myocardial infarction. During coronary angiography, an occlusion of the right coronary artery was identified. While removing the diagnostic catheter through the right radial artery, the patient experienced intense pain and discomfort, accompanied by a vasovagal reflex characterized by bradycardia and hypotension. Intravenous atropine (0.5mg) was administered, leading to a rapid rise in heart rate with frequent ventricular ectopy. Subsequently, a progressive and exaggerated elevation in arterial blood pressure occurred, peaking at 294/121mmHg approximately 10min after atropine administration. The patient developed hypertensive acute pulmonary edema, successfully treated with intravenous nitroglycerine (10mg) and furosemide (60mg). Blood pressure normalized after approximately 14min. The exact mechanism of atropine-induced hypertensive emergency remains unknown. While hypertensive emergencies with atropine are exceedingly rare, healthcare professionals should be aware of this potential effect and be prepared for prompt intervention.

¿Es necesario realizar un screening cardiovascular en los pacientes migrantes? / Is it necessary to perform cardiovascular screening in migrant patients?

Los pacientes migrantes que llegan a España a menudo proceden de países donde no existe acceso universal a la sanidad. Aunque la prevalencia de hipertensión arterial (HTA) es menor en África occidental que en España, existe una mayor prevalencia de HTA enmascarada debido a la ausencia de cribados de salud. Esto también puede producir que no se diagnostiquen a los pacientes con HTA secundaria. Presentamos el caso de un varón senegalés de 36 años, sin antecedentes patológicos conocidos, residente desde hacía un año en España, que debutó con una emergencia hipertensiva. En el momento del diagnóstico, el paciente presentaba daño grave de órgano diana (cardiopatía hipertensiva, retinopatía hipertensiva). Tras el estudio, se le diagnosticó hipertensión arterial secundaria a malformación de la arteria renal. Después de realizar la angioplastia, la presión arterial se normalizó y, a los 18 meses, el daño a los órganos diana se había reducido.(AU)

Migrant patients arriving in Spain often come from countries where there is no universal access to healthcare. Although the prevalence of arterial hypertension (HTN) is lower in West Africa than in Spain, there is a higher prevalence of masked HT due to the absence of health screening. Furthermore, patients with secondary hypertension may not be diagnosed. We present the case of a 36-year-old Senegalese man, with no known pathological history, resident for a year in Spain, who debuted with a hypertensive emergency. At the time of diagnosis, the patient had severe end-organ damage (hypertensive heart disease, hypertensive retinopathy). After the study, he was diagnosed with arterial hypertension secondary to malformation of the renal artery. After performing angioplasty, blood pressure normalized and, at 18 months, target organ damage had reduced. Migrants who arrive in our country must be incorporated into health screening systems to diagnose and treat possible unknown pathologies. In our case, the clue to secondary hypertension was the development of resistant hypertension with target organ damage in a young subject.(AU)

Is it necessary to perform cardiovascular screening in migrant patients? / ¿Es necesario realizar un screening cardiovascular en los pacientes migrantes?

Migrant patients arriving in Spain often come from countries where there is no universal access to healthcare. Although the prevalence of arterial hypertension (HTN) is lower in West Africa than in Spain, there is a higher prevalence of masked HT due to the absence of health screening. Furthermore, patients with secondary hypertension may not be diagnosed. We present the case of a 36-year-old Senegalese man, with no known pathological history, resident for a year in Spain, who debuted with a hypertensive emergency. At the time of diagnosis, the patient had severe end-organ damage (hypertensive heart disease, hypertensive retinopathy). After the study, he was diagnosed with arterial hypertension secondary to malformation of the renal artery. After performing angioplasty, blood pressure normalized and, at 18 months, target organ damage had reduced. Migrants who arrive in our country must be incorporated into health screening systems to diagnose and treat possible unknown pathologies. In our case, the clue to secondary hypertension was the development of resistant hypertension with target organ damage in a young subject.

Hipertensión maligna y feocromocitoma: reporte de un caso / Malignant hypertension and pheochromocytoma: a case report

La hipertensión arterial maligna se define por cifras extremadamente altas de presión arterial asociadas a daño orgánico. Constituye una causa de emergencia hipertensiva donde coexisten cifras elevadas de presión arterial, con hemorragia y exudados bilaterales retinianas (retinopatía hipertensiva grado III), con o sin papiledema (retinopatía hipertensiva grado IV), asociada usualmente a lesión renal o cardíaca. En un 1% de los casos es secundaria a causas endocrinológicas, entre ellas, la más frecuente: el feocromocitoma, que clásicamente se ha caracterizado por la tríada cefalea, sudoración y palpitaciones. Sin embargo, no existe un hallazgo clínico único que tenga un valor significativo en su diagnóstico. A continuación, presentamos el caso de una paciente de 23 años con emergencia hipertensiva y masa suprarrenal asociado a retinopatía hipertensiva grado IV. (AU)

Malignant arterial hypertension is defined by extremely high levels of pressure associated with organ damage. It is a cause of hypertensive emergency and is defined by the coexistence of high blood pressure and bilateral retinal haemorrhage or exudates (grade III hypertensive retinopathy), with or without papilloedema (grade IV hypertensive retinopathy) currently associated with organ damage such as renal or cardiac failure. Around 1% of malignant arterial hypertension is secondary to endocrinological causes, including the most common: pheochromocytoma, which is classically characterized by the triad: headache, sweating and palpitations. However, there is no single clinical finding that is of significant value in its diagnosis. We now present the case of a 23-year-old patient with a hypertensive emergency, an adrenal mass associated with grade IV hypertensive retinopathy. (AU)

[Malignant hypertension and pheochromocytoma: a case report]. / Hipertensión maligna y feocromocitoma: reporte de un caso.

Malignant arterial hypertension is defined by extremely high levels of pressure associated with organ damage. It is a cause of hypertensive emergency and is defined by the coexistence of high blood pressure and bilateral retinal haemorrhage or exudates (grade III hypertensive retinopathy), with or without papilloedema (grade IV hypertensive retinopathy) currently associated with organ damage such as renal or cardiac failure. Around 1% of malignant arterial hypertension is secondary to endocrinological causes, including the most common: pheochromocytoma, which is classically characterized by the triad: headache, sweating and palpitations. However, there is no single clinical finding that is of significant value in its diagnosis. We now present the case of a 23-year-old patient with a hypertensive emergency, an adrenal mass associated with grade IV hypertensive retinopathy.

Neuropatía óptica isquémica no arterítica como lesión de órgano diana en la hipertensión arterial / Non-arteritic ischaemic optic neuropathy as a target organ lesion in arterial hypertension

Varón de 39 años, de raza negra que consultó por pérdida de visión súbita e indolora del ojo derecho en el contexto de una crisis hipertensiva. Antecedente de hipertensión arterial esencial, sin control domiciliario por falta de adherencia terapéutica y con afectación de órganos diana: infarto lacunar, retinopatía hipertensiva grado IV e hipertrofia concéntrica del ventrículo izquierdo. La función renal era normal, sin albuminuria. El cuadro clínico se etiquetó de neuropatía óptica isquémica no arterítica tras descartarse enfermedad vascular, traumática, infecciosa o autoinmune. Presentó una discreta mejoría del déficit visual con el control de la presión arterial. Dados los antecedentes y las pruebas complementarias, se concluyó que la neuropatía óptica isquémica fue debida a malignización de su hipertensión arterial. (AU)

A 39-year-old black male who consulted with sudden and painless loss of vision in his right eye in the context of a hypertensive crisis. A history of essential arterial hypertension uncontrolled at home due to lack of therapeutic adherence and with target organ involvement: lacunar infarct, grade IV hypertensive retinopathy and left ventricular concentric hypertrophy. Renal function was normal, without albuminuria. The clinical picture was classified as non-arteritic ischaemic optic neuropathy after ruling out vascular, traumatic, infectious and autoimmune disease. The patient presented discrete improvement of the visual deficit with the control of blood pressure. From his history and complementary tests, it was concluded that the ischaemic optic neuropathy was due to malignization of his arterial hypertension. (AU)

[Non-arteritic ischaemic optic neuropathy as a target organ lesion in arterial hypertension]. / Neuropatía óptica isquémica no arterítica como lesión de órgano diana en la hipertensión arterial.

A 39-year-old black male who consulted with sudden and painless loss of vision in his right eye in the context of a hypertensive crisis. A history of essential arterial hypertension uncontrolled at home due to lack of therapeutic adherence and with target organ involvement: lacunar infarct, grade IV hypertensive retinopathy and left ventricular concentric hypertrophy. Renal function was normal, without albuminuria. The clinical picture was classified as non-arteritic ischaemic optic neuropathy after ruling out vascular, traumatic, infectious and autoimmune disease. The patient presented discrete improvement of the visual deficit with the control of blood pressure. From his history and complementary tests, it was concluded that the ischaemic optic neuropathy was due to malignization of his arterial hypertension.

Medidas preventivas y manejo diagnóstico y terapéutico de la hipertensión arterial y las crisis hipertensivas / Preventive measures and diagnostic and therapeutic management of arterial hypertension and hypertensive crises

Introducción: La hipertensión arterial (HTA) es definida por algunos como una enfermedad, aunque también se la considera como factor de riesgo cardiovascular. Hoy conocemos como las enfermedades cardiovasculares dependen más de la influencia simultánea de varios factores de riesgo que de la acción aislada de uno de ellos. Por ello, toda actividad preventiva en este campo, debe ser multifactorial y dirigida en diversos sentidos. Desarrollo: Cuando la HTA no es controlada se triplica la probabilidad de accidente cerebrovascular e insuficiencia cardiaca, con menor incidencia de enfermedad coronaria y arterial periférica. El propio aumento de la masa del ventrículo izquierdo, así como los cambios estructurales que tienen lugar a nivel del miocardio y de los vasos coronarios pueden desencadenar episodios de cardiopatía isquémica. El remodelado intersticial y el aumento de la masa del ventrículo izquierdo son factores predisponentes a la aparición de arritmias ventriculares y muerte súbita. Es importante evaluar y tratar a los pacientes recién diagnosticados con HTA con medicamentos adecuados y seguimiento para prevenir la progresión de la hipertensión no controlada a crisis hipertensivas, es decir, urgencia o emergencia hipertensiva. Conclusiones: El reconocimiento inmediato de una emergencia hipertensiva con las pruebas de diagnóstico apropiadas conducirá a una reducción adecuada de la presión arterial, aliviando la incidencia de consecuencias negativas a los órganos diana. El tratamiento adecuado ayudará a aliviar la progresión de la enfermedad y mejorar los resultados a largo plazo.

Introduction: Hypertension (HT) is defined by some as a disease, although it is also considered a cardiovascular risk factor. Today we know cardiovascular diseases depend more on the simultaneous influence of several risk factors than on the isolated action of one of them. Therefore, all preventive activity in this field must be multifactorial and directed in various ways. Developing: When HT is not controlled, the probability of stroke and heart failure, with a lower incidence of coronary and peripheral arterial disease triples. The increase in left ventricular mass itself, as well as, the structural changes that occur at the level of myocardium and coronary vessels, can trigger episodes of ischemic heart diseases. Interstitial remodeling and increased left ventricular mass are predisposing factors to the appearance of ventricular arrhythmias and sudden death. It is important to evaluate and treat newly diagnosed patients with HT with recommended medications and follow-up to prevent the progression of uncontrolled HT to hypertensive crises, that is, urgency or emergency hypertension. Conclusion: The immediate recognition of a hypertensive emergency with the affected diagnostic tests will lead to an adequate reduction of blood pressure, alleviating the incidence of negative consequences to the target organs. Proper treatment helps to decrease the progression of the disease and improves long-term outcomes.

[Malignant arterial hypertension (HTAM) with severe systolic dysfunction of the reversible left ventricle]. / Hipertensión arterial maligna (HTAM) con disfunción sistólica grave del ventrículo izquierdo reversible.

Malignant arterial hypertension is still present in current clinical care despite the fact that for more than three decades we have had a wide range of antihypertensive drugs to control high blood pressure. It is essential to know how to detect it in time due to its high risk to life, with poor short-term prognosis if not treated properly. It may present with nonspecific, but potentially serious, clinical symptoms or manifest clinically as a hypertensive emergency accompanied by hypertensive encephalopathy and multi-organ failure. We present a case of a 49-year-old woman, attended in our hospital who had an initial hypertension of 223/170mmHg accompanied by multi-organ failure, who progressed satisfactorily with antihypertensive treatment.

Hypertensive choroidopathy, retinopathy and optic neuropathy in renal transplantation failure. / Coroidopatía, retinopatía y neuropatía óptica hipertensiva en un paciente con fracaso de trasplante renal.

A 32 year-old man who presented with severe elevation of blood pressure after failure of kidney transplant. The patient had multiple serous retinal detachments, venous dilation, arteriolar narrowing, retinal haemorrhages, as well as optic disc oedema. Due to the impossibility of performing a fluorescein angiography, an angiotomography and en-face optical coherence tomography images were used to identify the vascular alterations in the retina, choroid, and choriocapillaris. Angiotomography and en face-optical coherence tomography mode images are very useful in cases where it is not possible to perform fluorescein angiography.

Hipertensão arterial e emergências hipertensivas / Hypertension and hypertensive emergencies

A crise hipertensiva é uma situação clínica comum, caracterizada pelo aumento acentuado e sintomático da pressão arterial, sendo subdividida em emergência e urgência hipertensiva. A emergência hipertensiva difere da urgência hipertensiva por apresentar um risco de morte iminente devido à lesão aguda ou em desenvolvimento nos órgãos-alvo, especialmente coração, cérebro, rins e artérias. Emergência hipertensiva requer uma abordagem clínica que avalie o órgão-alvo comprometido. A intervenção terapêutica deve ser imediata, eficiente e individualizada para cada sistema envolvido, em geral com fármacos anti- -hipertensivos por via endovenosa em unidade de terapia intensiva. Por outro lado, o paciente com urgência hipertensiva não apresenta lesão aguda em órgão-alvo e, portanto, não apresenta risco de morte. Sendo assim, o tratamento anti-hipertensivo pode ser realizado com medicamentos orais na sala de urgência. Este artigo revisa as principais situações clínicas relacionadas à emergência hipertensiva, sua apresentação clínico-epidemiológica, bem como sua abordagem clínica e terapêutica.

Hypertensive crisis is a common clinical situation characterized by a marked and symptomatic increase in blood pressure, being subdivided into emergency and hypertensive urgency. Hypertensive emergency presents an imminent risk of death due to acute or developing in target organs lesions, especially the heart, brain, kidneys and arteries. Hypertensive emergency requires a clinical approach that evaluates the compromised target organ. Therapeutic intervention should be immediate, efficient and individualized for each system involved, usually with intravenous antihypertensive drugs in the intensive care unit. On the other hand, the patient with hypertensive urgency does not present acute target organ injury and, therefore, has no risk of death. Thus, antihypertensive treatment can be performed with oral medications in the emergency room. This article reviews the main clinical situations related to hypertensive emergency, its clinical and epidemiological presentation, as well as its clinical and therapeutic approach.

Diagnóstico y tratamiento de las crisis hipertensivas en adultos en los tres niveles de atención: evidencias y recomendaciones / Diagnosis and treatment of hypertensive crises in adults at the three levels of care: evidence and recommendations

Es inevitable el aumento de los pacientes con Hipertensión Arterial Sistémica (HAS), de estos un porcentaje desarrollaran crisis hipertensivas en algún momento de su vida. La HAS es la causa responsable de casi 7 100 000 de muertes al año en todo el mundo. El objetivo de esta GPC es resumir las recomendaciones actuales del tratamiento de la crisis hipertensiva. En la presente guía se mencionan los diferentes fármacos utilizados, ya sea vía oral en urgencia hipertensiva o vía intravenosa en situación de emergencia hipertensiva, para cada una de las siguientes patologías: hipertensión maligna, encefalopatía hipertensiva, edema agudo pulmonar, enfermedad coronaria aguda, disección aórtica, evento vascular isquémico y hemorrágico y en la hipertensión perioperatoria; así como, el porcentaje a disminuir de las cifras tensionales en las primeras horas de inicio del manejo en cada una de estas entidades. Por lo tanto, en esta guía se tratarán de resolver las dudas más comunes en el abordaje de cada uno de los pacientes con crisis hipertensiva, además de valorar la eficacia y seguridad de los medicamentos para proteger la función de los órganos restantes, como también aliviar los síntomas, minimizar el riesgo de complicaciones y mejorar los resultados del paciente.

Diagnostic and therapeutic approach to the hypertensive crisis. / Aproximación diagnóstica y terapéutica de las crisis hipertensivas.

High blood pressure is a problem with elevated prevalence in the world population. The acute forms of presentation are "hypertensive crises," which represent a frequent cause for emergency room and primary care consultations. Hypertensive crises are divided into hypertensive emergencies and hypertensive urgencies, depending on whether or not there is acute damage to the target organ, respectively. Each situation has a different prognosis and treatment. More specifically, hypertensive emergencies are potentially serious and usually require rapid reductions in blood pressure, whereas hypertensive urgencies can be treated as outpatients by reducing blood pressure in hours or days. A significant number of patients who consult medical professionals regarding a hypertensive crisis do not have a prior diagnosis of hypertension; therefore, it is important to periodically monitor blood pressure levels in the community.

¿Podemos comenzar a cambiar nuestra "mirada" ante la urgencia hipertensiva? / Can we start changing our viewpoint towards hypertensive urgency?

La urgencia hipertensiva (UH) es una situación muy frecuente que asusta tanto a los pacientes como a sus familiares y al personal de salud y representa aproximadamente el 30% de las consultas no programadas (o de urgencia). En el presente artículo, los autores se hacen eco de publicaciones recientes y proponen dejar de utilizar el término urgencia hipertensiva para describir las situaciones de elevación de la presión arterial por encima de una tensión arterial sistólica ≥ 180 mmHg y/o una tensión arterial diastólica (TAD) ≥ 110 mmHg, sin asociación con daño de órgano blanco (con o sin sintomatología inespecífica concurrente), ya que los pacientes con este cuadro no corren riesgo inminente, no requieren atención médica de urgencia y, por lo tanto, deberían enmarcarse dentro de los cuidados habituales de los pacientes con factores de riesgo cardiovascular y riesgo cardiovascular global elevado. Esto implica no solo un cambio semántico, sino un desafío en el abordaje y manejo de estas situaciones tan frecuentes. (AU)

Hypertensive urgency (UH) is a very frequent clinical situation that scares patients, their families as well as health care provid-ers and represents approximately 30% of the non-scheduled (or urgent) visits. In the present article, taking into account recent publications, the authors propose to stop using the term hypertensive urgency to describe situations of elevated blood pressure above systolic blood pressure ≥ 180 mmHg and / or diastolic blood pressure ( TAD) ≥ 110 mmHg, without end organ dam-age (with or without concurrent non-specific symptomatology), since patients with this condition are not at imminent risk, do not require urgent medical attention and should therefore be framed within usual care of patients with cardiovascular risk factors and high overall cardiovascular risk. This implies not only a semantic change, but a challenge in the approach and management of these frequent situations. (AU)

Manejo anestésico de emergencia hipertensiva perioperatoria secundaria a tumores neuroendocrinos A propósito de un caso / Anesthetic management of hypertensive emergency perioperative secondary neuroendocrine tumors. Report of a case

Resumen Introducción: Los tumores neuroendocrinos son neoplasias secretoras de hormonas, principalmente catecolaminas, que pueden presentarse en cualquier parte del cuerpo. La incidencia del feocromocitoma es de 2 a 8 por millón de personas por año, y el 10% de ellos son tumores extra adrenales. El manejo anestésico se considera un reto para el anestesiólogo, ya que deben tomar en cuenta varios puntos para el control hemodinámico del paciente, así como el manejo multidisciplinario en el periodo pre, trans y posquirúrgico. Caso clínico: Presentamos el caso de un paciente masculino portador de para-ganglioma vesical sometido a resección quirúrgica bajo anestesia general e infusión de isosorbide para control de la emergencia hipertensiva. Conclusiones: Se consideró, en este caso en particular, que el uso de vasodilatadores periféricos fue benéfico para el tratamiento de la emergencia hipertensiva durante el transanestésico. Discusión: El tratamiento de la emergencia hipertensiva reportado en la bibliografía muestra que el uso de fármacos intravenosos como nitroprusiato de sodio, nitroglicerina, labetalol, esmolol, entre otros, son los más indicados. El uso de nitritos es una alternativa viable con descontrol hipertensivo severo.

Abstract Introduction: Neuroendocrine tumors, can be found anywhere on the body. The incidence of pheochromocytoma is 2-8 per million people per year and 10% of these are extra-adrenal tumors. Anesthetic management is considered a challenge for the anesthesiologist, since they are primarily catecholamine secreting tumors, and they must take into account several points for a hemodynamic monitoring of the patient and the multidisciplinary management in the pre, trans and postsurgical period. Case report: We report the case of a male patient carrier of a bladder para-ganglioma who underwent a surgical resection under general anesthesia and an infusion of isosorbide to control a hypertensive emergency. Conclusions: We considered, in this particular case, that the use of peripheral vasodilators was beneficial for the treatment of hypertensive emergency during trans- anesthetic. Discussion: The treatment of hypertensive emergencies reported in the literature shows that the use of intravenous drugs such as sodium nitroprusside, nitroglycerin, labetalol, esmolol, among others, are the most recommended. The use of nitrite is a viable alternative with severe uncontrolled hypertension.

Acute Arterial Hypertension in Patients undergoing Neurosurgery

Introduction Between 20­50% of neurosurgical patients may develop early perioperative complications, and 25% have more than one clinical complication. The most commons are high blood pressure (25%) and cardiovascular events (7%). Intraoperative hypertension is characterized by an increase of 20% in basal blood pressure. Objectives The aim of this paper is to review and discuss the pathophysiology, diagnosis and treatment of perioperative hypertension in patients undergoing neurosurgery, and to propose one table with therapeutic options. Methods A review using Scielo, PubMed, Ebsco and Artmed databases with inclusion and exclusion criteria. Articles published from 1957 to 2015 were selected. Discussion Five factors were established as causes: arterial hypertension, clinical conditions, surgical procedures, and operative and anesthetic factors. Specific causes preoperative, intraoperative and posoperative. The pathophysiology may have some relationship with catecholamines and sympathetic nervous system stimulation. Conclusion Perioperative hypertension in neurosurgery may have many causes, some of them recognizable and preventable. This increased pressure may be associated with intracranial hematomas in some cases. The recognition and treatment of this disease can be helpful in the management of the postoperative period.

Introdução Entre 20­50% dos pacientes neurocirúrgicos podem desenvolver complicações perioperatórias precoces, e cerca de 25% têm mais de uma complicação clínica. A complicação mais comum é pressão arterial elevada (25%); eventos cardiovasculares (7%). Hipertensão Arterial intraoperatória é considerada quando se aumenta 20% o valor absoluto do seu valor da pressão de base. Objetivos O objetivo deste artigo é discutir a fisiopatologia, diagnóstico e tratamento da hipertensão perioperatória em pacientes que passaram por neurocirurgia, e propor uma tabela com opções terapêuticas. Métodos Revisão utilizando as bases de dados SciELO, PubMed, Ebsco e Artmed com os critérios de inclusão e exclusão. Artigos publicados de 1957 a 2015. Discussão Cinco fatores foram estabelecidos como causas: hipertensão, condições clínicas, os procedimentos cirúrgicos, fatores operatórios e fatores anestésicos. Existem causas específicas préoperatório, intraoperatório e pós-operatório estabelecidas. A fisiopatologia pode ter alguma relação com catecolaminas e com a estimulação simpático do sistema nervoso. Conclusão A hipertensão perioperatória na neurocirurgia pode ter várias causas, algumas delas reconhecíveis. Este aumento da pressão arterial pode estar associado à incidência de hematomas intracranianos. Reconhecimento e manejo adequado da doença pode ajudar no controle da pressão durante o período pós-operatório.

Dissecção de aorta: diagnóstico diferencial e manejo / Aortic dissection: differential diagnosis and management

A dissecção de aorta é a patologia de maior mortalidade entre as síndromes aórticas agudas com início súbito de dor torácica, sendo 1% por hora, nas primeiras 48 horas e 75% ao final da segunda semana. Menos de 10 % dos pacientes não tratados sobrevivem por um ano1. Por isso, é necessário conhecer a fisiopatologia, a classificação, a apresentação clínica e o diagnóstico diferencial desta patologia, para que o diagnóstico seja evidente, garantindo, assim, o manejo adequado e o melhor desfecho do quadro clínico. O objetivo deste artigo de revisão é fornecer uma estratégia diagnóstica e terapêutica organizada ao clínico, direcionando o conhecimento médico para as manifestações clínicas e para abordagem terapeutica inicial com rapidez, qualidade e eficiência no pronto atendimento.

Aortic dissection is the pathology of higher mortality among the acute aortic syndromes of sudden onset of chest pain, being 1% per hour in the first 48 hours and 75% at the end of the second week. Less than 10% of untreated patients survive for one year. So it is necessary to know the pathophysiology, classification, clinical presentation and differential diagnosis of this disease, so the diagnosis is evident, thus ensuring proper management and the best outcome of the clinical condition. Therefore, the aim of this review article is to provide a diagnostic and therapeutic strategy organized to the professional, directing the medical knowledge to the clinical manifestations and initial therapeutic approach with speed, quality and efficiency of care in the emergency room.

Emergência hipertensiva nas síndromes coronárias agudas / Acute coronary syndrome in hypertensive emergencies

Há uma forte relação da hipertensão arterial com manifestações clínicas da coronariopatia. A emergência hipertensiva associada a um quadro isquêmico miocárdico agudo, angina instável ou infarto agudo do miocárdio requer tratamento rápido e seguro, para controle dos níveis pressóricos e redução do fenômeno isquêmico. Dentre os recursos terapêuticos disponíveis por via endovenosa, destacam-se a nitroglicerina e os betabloqueadores, ambos contribuindo para melhora do fluxo sanguíneo coronário e, ao mesmo tempo, reduzindo o consumo de oxigênio miocárdico. Os altos níveis de pressão arterial na vigência do infarto agudo do miocárdio tornam-se uma séria contraindicação para o emprego imediato de trombolítico no tratamento de reperfusão e o risco de acidente vascular cerebral é elevado. Portanto, devemos retardar esse tipo de recurso ou utilizar a via percutânea para angioplastia como tratamento ideal.

Arterial hypertension has a strong relationship with clinical manifestation of coronary heart disease. The hypertensive emergency associated with an acute myocardial ischemia, instable angina or an acute myocardial infarct needs a fast and safe procedure, to control the arterial pressure and reduce ischemic phenomenon. Among the available therapeutic resources by intravenous way, we can highlight nitroglycerine and betablockers, in that both reduce myocardial oxygen consumption and improve coronary flow. The high levels of arterial pressure in acute myocardial infarct become a serious contraindication for the immediate use of thrombolytic agents in reperfusion treatment and the risk for stroke is high. Thus, we should delay this action or use percutaneous way for angioplasty as a better treatment.

Tratamento da emergência hipertensiva na dissecção aórtica / Treatment of hypertensive emergency in aortic dissection

A dissecção aórtica é a mais letal das emergências cardiovasculares e, portanto, requer diagnóstico preciso imediato e intervenções terapêuticas clínica e intervencionista em regimes de urgência. Os métodos de imagens, como a ecocardiografia e a angiotomografia, são os métodos diagnósticos de escolha e devem ser considerados na suspeita clínica de dissecção aórtica. A hipertensão é o principal fator de risco para a dissecção e, com frequência, o paciente com dissecção aórtica se apresenta com um quadro de emergência hipertensiva que requer terapêutica rigorosa e imediata. O objetivo da terapêutica é o imediato controle da pressão arterial com nitroprussiato de sódio e a redução da frequência cardíaca com betabloqueador endovenoso, reduzindo a pressão de pulso e o stress parietal na aorta e reduzindo o risco de rotura da aorta ou propagação anterógrada ou retrógada da dissecção. Feito o diagnóstico, a dissecção que envolve a aorta ascendente (Tipo A) deve ser tratada cirurgicamente em regime de emergência. Adissecção restrita à aorta descendente (Tipo B) recebe abordagem clínica inicial e, na vigência de complicações como expansão da falsa luz, hemotórax, dor persistente ou isquemia visceral, deve ser tratada invasivamente com o implante endovascular de stents

Aortic dissection is the most lethal cardiovascular emergencies and, therefore, it requires prompt and accurate diagnosis as well as interventional and clinical therapeutic interventions in emergency regimes. Theimaging methods, such as echocardiography and angiotomography, are the diagnostic methods of choice and should be considered in clinical suspicion of aortic dissection. Hypertension is the leading risk factor for dissection and often the patient with aortic dissection presents with a case of hypertensive emergency that requires accurate and immediate therapy. The goal of therapy is the immediate control of blood pressure withsodium nitroprusside and the heart rate reductionwith intravenous beta-blocker, reducing pulse pressure and the parietal stress in the aorta and the risk of aortic rupture or anterograde or retrograde propagation of dissection. Diagnosed dissection involving the ascending aorta (Type A) should be surgically treated in emergency. The dissection restricted to the descending aorta (Type B) receives initial clinical approach and, in the presence of complications such as expansion of the false lumen, hemothorax, persistent pain or visceral ischemia, it should be treated invasively with endovascular stenting.