Management of hypertensive crises in the el(5)

6 Other agents

Several other agents have been used to treat hypertensive crises in the elderly, including enalaprilat, diazoxide, and trimethaphan camsylate.[81–83] However, these drugs are associated with significant side effects, and should not be considered as primary choices in elderly patients.[84]

Enalaprilat is an intravenous angiotensin converting enzyme (ACE) inhibitor, with an onset of action of 15 min.[85] It may be beneficial in managing hypertensive crises with congestive heart failure in some patients.[81] As an ACE inhibitor, it can potentially compromise the already declined renal function in elderly patients making it less favorable option.[16] In addition, reflex tachycardia due to hypotension may be present.[4,34]

Trimethaphan camsylate is a non-depolarizing sympathetic and parasympathetic ganglia blocker.[4] It competes with acetylcholine for cholinergic receptors.[4] This medication is effective in decreasing BP, but is associated with significant side effects, including tachycardia and exacerbation of ischemic heart disease; therefore, its use should be avoided in the elderly.[86]

Diazoxide is another potent peripheral vasodilating agent.[87] When administered intravenously, diazoxide can precipitate severe hypotension and ischemic heart disease.[88]

All of these therapeutic agents, in our opinion, are dangerous options in managing hypertensive crises in the elderly and should be avoided.

7 Conclusions

The management of hypertensive crises in the elderly is a clinical challenge to the treating clinician. The pathophysiological changes in these patients make them more vulnerable to complications. Therefore, extensive knowledge of the available agents, their side effects, and interactions with other agents, is essential for a successful outcome. We recommend using easily titratable agents, such as clevidipine, nicardipine, esmolol, and fenoldopam as first choices and avoid agents such as nitroprusside, hydralazine, and nifedipine due to their established side effects.

J Geriatr Cardiol 2018; 15: 504?512. doi:10./

1 Introduction

Hypertension (HTN) remains a common illness around the World.[1]Uncontrolled HTN can lead to hypertensive crises. These are divided into two groups, urgencies and emergencies.[2]Both of them involve severe elevations of blood pressure (BP) more than 180/120 mmHg.[3]The core difference between them is whether severe HTN causes any organ dysfunction (hypertensive emergency) or not (urgency).[1,3]These crises are common among the elderly.

Management of hypertensive crises in elderly patients should integrate a comprehensive set of pharmacological strategies, depending on the core pathophysiological changes related to aging, preexisting risk factors, coexistent comor-bidities, speed of progression of the condition, and the ex-tensiveness of organs involvement. Failure to successfully manage these crises in the elderly is associated with significant morbidity and mortality.[4]

2 Epidemiology and pathophysiology

HTN is one of the most important diseases among in the elderly population. According to the National Health and Nutrition Examination Survey during 2015–2016, 63.1% of American people aged > 60 years have elevated blood pressure.[5]The vast majority of these patients have essential HTN.[6]In addition, HTN remains a major risk factor for cerebrovascular as well as cardiovascular diseases, two of the leading causes of death in the United States causing about 770,000 deaths only in 2016.[7]

The incidence of HTN, and hence, its complications such as hypertensive crises, is different among different groups, and is higher in the elderly and African-Americans.[8–11]Hypertension is not just more prevalent in elderly people, but mortality and morbidity are more significant as well.[12]The investigators of the multicenter STAT registry reported a hospital mortality rate of 6.9% among patients with acute hypertensive crises requiring hospitalization and a cumulative 90 day mortality of 11% among these patients.[13]

Severe HTN is predominant among patients with history ofHTN in the majority of cases.[10]Many of them have inadequate previous medical management, or poor compliance to treatment.[12]Those preventable causes should be addressed and treated, as the recurrence rate of acute hypertensive crises is high. The STAT investigators reported a 90-day readmission rate of 37%, of which, 25% were due to recurrent acute hypertensive crises.[13]

To understand the extent of HTN among the elderly, one must be aware of the pathophysiology of this entity. The regulation of BP is a concert of several organs/systems. The most important mechanisms are the cardiac output and systemic vascular resistance (SVR).[14]Elderly people suffer increased SVR and, hence, elevated BP.[15]Several mechanisms have been suggested to explain the increase in SVR, such as endothelial dysfunction, neuro-hormonal dysregulation, and a reduction in renal homeostatic mechanisms due to decreased glomerular filtration rate (Figure 1).[14,16,17]

文章来源：《中国药理学与毒理学杂志》 网址: http://www.zgylxydlxzz.cn/qikandaodu/2020/1010/350.html