- Email: [email protected]
Ramipril and hydrochlorothiazide treatment of hypertensive urgency in the ED
Correspondence / American Journal of Emergency Medicine 31 (2013) 1525–1534
References [1] Gümüş T, Yıldırım D, Uçar G. Lung injury and pneumothorax after defibrillation as demonstrated with computed tomography. Am J Emerg Med 2013;31(6): 1003.e1–3. [2] Vollmann D, Lüthje L, Seegers J, Sohns C, Dorenkamp M, Vafa A, et al. Sternal fracture after elective electrical cardioversion of atrial fibrillation. Clin Res Cardiol 2011;100:261–2. [3] Brinn LB, Moseley JE. Bone changes following electrical injury; case report and review of literature. Am J Roentgenol Radium Ther Nucl Med 1966;97(3):682–6. [4] Mahlfeld A, Franke J, Mahlfeld K. Ultrasound diagnosis of sternum fractures. Zentralbl Chir 2001;126:62–4.
The relation between N-terminal pro–B-type natriuretic peptide and heart failure☆ To the Editor, We read the article “Predictive cutoff point of admission Nterminal pro–B-type natriuretic peptide (NT-proBNP) testing in the emergency department (ED) for prognosis of patients with acute heart failure (HF)” by Golcuk et al with interest [1]. The authors aimed to determine a cutoff level of plasma NT-proBNP that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the ED. They concluded that elevated NT-proBNP levels at the time of admission are a strong and independent predictor of allcause mortality in patients with acute heart failure at 30 days and 1 year after admission. Although most widely used as a marker of systolic heart failure, elevated NT-proBNP has been reported in patients with diastolic dysfunction [2]. Therefore, it is important to determine diastolic and systolic function by echocardiography. Performing echocardiography is also important for measurement of pulmonary artery pressure. Pulmonary arterial hypertension is frequently seen in rheumatic diseases and NT-proBNP levels may be a result of the increase in pulmonary pressure [3]. On the other hand, high levels of NT-proBNP can be observed in many cases which increase cardiac output and cardiac stress such as sepsis, cirrhosis, and hyperthyroidism [4]. In context, determination of liver test and thyroid hormones profile may reveal a stronger results in such a study. Furthermore, renal dysfunction may predict HF and could estimate the risk of mortality and morbidity for HF [5]. Although it is important to measure the creatinine clearance by glomerular filtration rate (GFR), they had not given information about it. There are different methods for GFR measurement in clinical practice. The Cockcroft-Gault equation and the modification of diet in renal disease (MDRD) are commonly used method for calculating the GFR. However, the Cockcroft-Gault equation may estimate lower GFR in younger age groups compared with the MDRD formula, but it can measure higher GFR in older individuals compared with the MDRD formula [6]. In conclusion, elevated NT pro-BNP may strongly predicts all-cause mortality and morbidity of patients with HF [7]. However, higher NT pro-BNP may be associated very different conditions and the pivotal roles of those factors evaluate further large-scale prospective randomized clinical trials. Sevket Balta Sait Demirkol Ugur Kucuk Murat Unlu Zekeriya Arslan Turgay Celik
☆ There is no conflict of interests.
MD MD MD MD MD MD
1533
Department of Cardiology Gulhane Medical Academy Ankara Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.07.022 References [1] Golcuk Y, Golcuk B, Velibey Y, Oray D, Atilla OD, Colak A, et al. Predictive cutoff point of admission N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure. Am J Emerg Med. Elsevier Inc.; 2013;13–7. [2] Tschöpe C, Kasner M, Westermann D, Gaub R, Poller WC, Schultheiss H-P. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. Eur Heart J 2005;26(21): 2277–84. [3] Mirjafari H, Welsh P, Verstappen SMM, Wilson P, Marshall T, Edlin H, et al. Nterminal pro-brain-type natriuretic peptide (NT-pro-BNP) and mortality risk in early inflammatory polyarthritis: results from the Norfolk Arthritis Registry (NOAR). Ann Rheum Dis 2013. [Epub ahead of print]. [4] Aydogan M, Balta S, Kurt O, Sarlak H, Gumus S, Demirkol S. The reasons of higher NT-proBNP depend on very different conditions. Ann Rheum Dis 2013; 72(7):e17. [5] Balta S, Demirkol S, Karaman M. Renal dysfunction may predict new onset heart failure. Am Heart J. 2013. [Epub ahead of print]. [6] Demirkol S, Balta S, Kucuk U, Karaman M, Kucuk HO, Kurt O. Neutrophil-tolymphocyte ratio may predict contrast-induced nephropathy. Angiology 2013. [7] Balta S, Demirkol S, Aydogan M, Celik T. Higher NT-proBNP May be related to very different conditions. J Am Coll Cardiol. 2013; Article in press.
Ramipril and hydrochlorothiazide treatment of hypertensive urgency in the ED To the Editor, Hypertensive urgencies are a frequent cause for consultation at the emergency department (ED). There are multiple approaches to treating this presentation, and we endeavored to assess the safety and efficacy of an oral treatment with 10 mg of ramipril and 12.5 mg of hydrochlorothiazide to treat hypertensive urgencies (which we define as systolic blood pressure of N 180 mmHg and/or diastolic blood pressure of N120 mmHg with absence of acute target organ disease in the ED) [1]. We enrolled 620 patients with hypertensive urgency prospectively and consecutively in our study. The mean age was 61.4 ± 10.7 years, 50% of patients were male, and 80% of the total number of patients had diagnosis of hypertension. All patients were discharged from the ED with 10 mg of ramipril and 12.5 mg of hydrochlorothiazide when the systolic blood pressure was b 160 mmHg and/or diastolic blood pressure was b100 mmHg [2]. There were no adverse events reported; 87% of patients were discharged after 3 ± 1.2 hours upon arrival at the ED, but 13% of patients were admitted into the coronary care unit to receive intravenous treatment [3,4]. We have concluded that 10 mg of ramipril and 12.5 mg of hydrochlorothiazide can be a safe and effective treatment for hypertensive urgency in the ED.
Diego Conde MD Florencia Castro MD Milagros Caro MD Instituto Cardiovascular de Buenos Aires Buenos Aires 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.07.024
1534
Correspondence / American Journal of Emergency Medicine 31 (2013) 1525–1534
References [1] Zampaglione B, Pascale C, Marchisio M, et al. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996;27:144–7. [2] Komsuoglu SS, Komsuoglu B, Ozmenoglu M, et al. Oral nifedipine in the treatment of hypertensive crises in patients with hypertensive encephalopathy. Int J Cardiol 1992;34:277–82.
[3] The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157: 2413–46. [4] Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group. Lancet 1998;351:1755–62.
References [1] Gümüş T, Yıldırım D, Uçar G. Lung injury and pneumothorax after defibrillation as demonstrated with computed tomography. Am J Emerg Med 2013;31(6): 1003.e1–3. [2] Vollmann D, Lüthje L, Seegers J, Sohns C, Dorenkamp M, Vafa A, et al. Sternal fracture after elective electrical cardioversion of atrial fibrillation. Clin Res Cardiol 2011;100:261–2. [3] Brinn LB, Moseley JE. Bone changes following electrical injury; case report and review of literature. Am J Roentgenol Radium Ther Nucl Med 1966;97(3):682–6. [4] Mahlfeld A, Franke J, Mahlfeld K. Ultrasound diagnosis of sternum fractures. Zentralbl Chir 2001;126:62–4.
The relation between N-terminal pro–B-type natriuretic peptide and heart failure☆ To the Editor, We read the article “Predictive cutoff point of admission Nterminal pro–B-type natriuretic peptide (NT-proBNP) testing in the emergency department (ED) for prognosis of patients with acute heart failure (HF)” by Golcuk et al with interest [1]. The authors aimed to determine a cutoff level of plasma NT-proBNP that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the ED. They concluded that elevated NT-proBNP levels at the time of admission are a strong and independent predictor of allcause mortality in patients with acute heart failure at 30 days and 1 year after admission. Although most widely used as a marker of systolic heart failure, elevated NT-proBNP has been reported in patients with diastolic dysfunction [2]. Therefore, it is important to determine diastolic and systolic function by echocardiography. Performing echocardiography is also important for measurement of pulmonary artery pressure. Pulmonary arterial hypertension is frequently seen in rheumatic diseases and NT-proBNP levels may be a result of the increase in pulmonary pressure [3]. On the other hand, high levels of NT-proBNP can be observed in many cases which increase cardiac output and cardiac stress such as sepsis, cirrhosis, and hyperthyroidism [4]. In context, determination of liver test and thyroid hormones profile may reveal a stronger results in such a study. Furthermore, renal dysfunction may predict HF and could estimate the risk of mortality and morbidity for HF [5]. Although it is important to measure the creatinine clearance by glomerular filtration rate (GFR), they had not given information about it. There are different methods for GFR measurement in clinical practice. The Cockcroft-Gault equation and the modification of diet in renal disease (MDRD) are commonly used method for calculating the GFR. However, the Cockcroft-Gault equation may estimate lower GFR in younger age groups compared with the MDRD formula, but it can measure higher GFR in older individuals compared with the MDRD formula [6]. In conclusion, elevated NT pro-BNP may strongly predicts all-cause mortality and morbidity of patients with HF [7]. However, higher NT pro-BNP may be associated very different conditions and the pivotal roles of those factors evaluate further large-scale prospective randomized clinical trials. Sevket Balta Sait Demirkol Ugur Kucuk Murat Unlu Zekeriya Arslan Turgay Celik
☆ There is no conflict of interests.
MD MD MD MD MD MD
1533
Department of Cardiology Gulhane Medical Academy Ankara Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.07.022 References [1] Golcuk Y, Golcuk B, Velibey Y, Oray D, Atilla OD, Colak A, et al. Predictive cutoff point of admission N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure. Am J Emerg Med. Elsevier Inc.; 2013;13–7. [2] Tschöpe C, Kasner M, Westermann D, Gaub R, Poller WC, Schultheiss H-P. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. Eur Heart J 2005;26(21): 2277–84. [3] Mirjafari H, Welsh P, Verstappen SMM, Wilson P, Marshall T, Edlin H, et al. Nterminal pro-brain-type natriuretic peptide (NT-pro-BNP) and mortality risk in early inflammatory polyarthritis: results from the Norfolk Arthritis Registry (NOAR). Ann Rheum Dis 2013. [Epub ahead of print]. [4] Aydogan M, Balta S, Kurt O, Sarlak H, Gumus S, Demirkol S. The reasons of higher NT-proBNP depend on very different conditions. Ann Rheum Dis 2013; 72(7):e17. [5] Balta S, Demirkol S, Karaman M. Renal dysfunction may predict new onset heart failure. Am Heart J. 2013. [Epub ahead of print]. [6] Demirkol S, Balta S, Kucuk U, Karaman M, Kucuk HO, Kurt O. Neutrophil-tolymphocyte ratio may predict contrast-induced nephropathy. Angiology 2013. [7] Balta S, Demirkol S, Aydogan M, Celik T. Higher NT-proBNP May be related to very different conditions. J Am Coll Cardiol. 2013; Article in press.
Ramipril and hydrochlorothiazide treatment of hypertensive urgency in the ED To the Editor, Hypertensive urgencies are a frequent cause for consultation at the emergency department (ED). There are multiple approaches to treating this presentation, and we endeavored to assess the safety and efficacy of an oral treatment with 10 mg of ramipril and 12.5 mg of hydrochlorothiazide to treat hypertensive urgencies (which we define as systolic blood pressure of N 180 mmHg and/or diastolic blood pressure of N120 mmHg with absence of acute target organ disease in the ED) [1]. We enrolled 620 patients with hypertensive urgency prospectively and consecutively in our study. The mean age was 61.4 ± 10.7 years, 50% of patients were male, and 80% of the total number of patients had diagnosis of hypertension. All patients were discharged from the ED with 10 mg of ramipril and 12.5 mg of hydrochlorothiazide when the systolic blood pressure was b 160 mmHg and/or diastolic blood pressure was b100 mmHg [2]. There were no adverse events reported; 87% of patients were discharged after 3 ± 1.2 hours upon arrival at the ED, but 13% of patients were admitted into the coronary care unit to receive intravenous treatment [3,4]. We have concluded that 10 mg of ramipril and 12.5 mg of hydrochlorothiazide can be a safe and effective treatment for hypertensive urgency in the ED.
Diego Conde MD Florencia Castro MD Milagros Caro MD Instituto Cardiovascular de Buenos Aires Buenos Aires 1428, Argentina E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.07.024
1534
Correspondence / American Journal of Emergency Medicine 31 (2013) 1525–1534
References [1] Zampaglione B, Pascale C, Marchisio M, et al. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996;27:144–7. [2] Komsuoglu SS, Komsuoglu B, Ozmenoglu M, et al. Oral nifedipine in the treatment of hypertensive crises in patients with hypertensive encephalopathy. Int J Cardiol 1992;34:277–82.
[3] The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997;157: 2413–46. [4] Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group. Lancet 1998;351:1755–62.