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Oral agents Nifedipine (Adalat, Procardia) Clonidine (Catapres) Captopril (Capoten) Calcium channel blocker Central sympatholytic ACE inhibitor 10 mg initially; may be repeated after 30 minutes 01 02 mg initially; then 01 mg every hour to 08 mg 125 25 mg 15 minutes 2 6 hours Response unpredictable

4:

children, but even in these situations, newer agents are supplanting it 10 Trimethaphan The ganglionic blocking agent trimethaphan is titrated with the patient sitting; its activity depends on this The patient can be placed supine if the hypotensive effect is excessive The effect occurs within a few minutes and persists for the duration of the infusion This agent has largely been replaced by nitroprusside and newer medications 11 Diuretics Intravenous loop diuretics can be very helpful when the patient has signs of heart failure or fluid retention, but the onset of their hypotensive response is slow, making them an adjunct rather than a primary agent for hypertensive emergencies Low dosages should be used initially (furosemide, 20 mg or bumetanide, 05 mg) They facilitate the response to vasodilators, which often stimulate fluid retention

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blood pressure over a period of several hours Sedation is frequent, and rebound hypertension may occur if the drug is stopped 2 Captopril Captopril, 125 25 mg orally, will also lower blood pressure in 15 30 minutes The response is variable and may be excessive 3 Nifedipine The effect of fast-acting nifedipine capsules is unpredictable and may be excessive, resulting in hypotension and reflex tachycardia Because myocardial infarction and stroke have been reported in this setting, the use of sublingual nifedipine is not advised

When the blood pressure has been brought under control, combinations of oral antihypertensive agents can be added as parenteral drugs are tapered off over a period of 2 3 days Most subsequent regimens should include a diuretic

Flanigan JS et al Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat Med Clin North Am 2006 May;90(3):439 51 [PMID: 16473099] Khanna A et al Malignant hypertension presenting as hemolysis, thrombocytopenia, and renal failure Rev Cardiovasc Med 2003 Fall;4(4):255 9 [PMID: 14674379] Migneco A et al Hypertensive crises: diagnosis and management in the emergency room Eur Rev Med Pharmacol Sci 2004 Jul Aug;8(4):143 52 [PMID: 15636400]

Patients with less severe acute hypertensive syndromes can often be treated with oral therapy Abrupt blood pressure lowering is not usually necessary in asymptomatic individuals, and the use of agents such as rapid-acting nifedipine probably causes more adverse effects than benefits 1 Clonidine Clonidine, 02 mg orally initially, followed by 01 mg every hour to a total of 08 mg, will usually lower

is a common complaint Femoral pulses are absent or very weak as are the distal pulses A bruit may be heard over the aorta, iliac, and femoral arteries

The ratio of systolic blood pressure at the ankle compared with the brachial artery of the upper arm, as detected by Doppler examination, is reduced to below 09 (normal ratio is 10 12); this difference is exaggerated by exercise Segmental wave-forms or pulse volume recordings obtained by strain gaze technology through blood pressure cuffs demonstrate blunting of the arterial inflow throughout the leg

FIGURE 4-5

Cramping; pain or tiredness in the calf, leg, or hip while walking (claudication) Diminished femoral pulses Tissue loss (ulceration, gangrene) unusual

CT angiography (CTA) and magnetic resonance angiography (MRA) have largely replaced traditional invasive angiography to determine the anatomic locations of the occlusions Imaging is only required when intervention is contemplated, since a segmental wave-form analysis should appropriately identify the involved levels of the arterial tree

The classic patient with aortoiliac disease is a 50- to 60-yearold male smoker in whom this is the initial manifestation of systemic atherosclerosis Occlusive disease of the aorta and iliac arteries begins most frequently at the bifurcation of the aorta in the proximal common iliac arteries Lesions affecting the external iliac arteries are less common Disease progression may lead to complete occlusion of one or both common iliac arteries, which can precipitate occlusion of the entire abdominal aorta to the level of the renal arteries Pathologic changes of atherosclerosis may be diffuse, but flow-limiting stenoses occur segmentally This is particularly true of the aortoiliac segment where patients may have limited or no narrowing of the vessels in the more distal vessels

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