ABC | Volume 114, Nº4, April 2020

Statement Luso-Brazilian Position Statement on Hypertensive Emergencies – 2020 Arq Bras Cardiol. 2020; 114(4)736-751 Figure 4 – Imaging methods for diagnostic confirmation of pheochromocytoma. Table 5 – Preoperative care in cases of pheochromocytoma High-sodium diet and hydration (lacks evidence): - Saline infusion during surgery (1 to 2 L) - Revert volume contraction - Prevent hypotension Pharmacological preparation: - Alpha-adrenergic blockade - Beta-blockers - Calcium-channel blockers - No evidence regarding target blood pressure Laparoscopic adrenalectomy (most cases): - For paragangliomas (minority) Open adrenalectomy (for paragangliomas): - For pheochromocytoma (minority) Imaging Methods Indication: Abnormal biochemical test Computed Tomography Magnetic Resonance Imaging - Greater than magnetic resonance imaging - Best chest, abdominal and pelvis resolution - Greater than paraganglioma tomography - Other events Contrast allergy Limited exposure to contrast (children, pregnant women) cocaine use are intensified by alcohol consumption. 80 Cocaine-induced vasoconstriction is secondary to stimulation of alpha-adrenergic receptors in the smooth muscle cells of the coronary circulation. This drug also increases the release of endothelin-1 81 and decreases the bioavailability of nitric oxide, promoting BP elevation. 82 Treatment with benzodiazepines is initially indicated. When BP reduction is required, a competitive intravenous alpha-blocker agent is indicated (phentolamine). Alternatively, nicardipine or sodium nitroprusside may be considered. 83 Clonidine may also be considered because of its sedative effect in addition to sympatholytic action. In ACS, treatment with nitroglycerin and aspirin is recommended concomitantly with benzodiazepines. In the presence of ACS with tachyarrhythmias, non-dihydropyridine calcium-channel blockers (diltiazem and verapamil) are recommended. Beta-blockers (including labetalol) are contraindicated since these agents are unable to reduce the coronary vasoconstriction. 84 Nicardipine may also be a good alternative for patients with HE induced by cytotoxic or antiangiogenic drugs. 14. Postoperative Hypertensive Emergency Following Vascular Surgery The concept of “postoperative hypertensive emergency” differs from that of ambulatory hypertensive emergency/ urgency because of the occurrence of this unique clinical situation in an atypical (postoperative) setting. Notably, moderately elevated BP values in the postoperative setting may require immediate treatment. 85 Postoperative hypertensive emergency (POHE) is arbitrarily defined as elevation of SBP to levels > 190 mmHg and/or DBP to levels > 100 mmHg confirmed in two consecutive readings during the immediate postoperative period. 86 A 40 to 50 mmHg elevation in SBP or increase in BP values greater than 20% in relation to baseline values may also characterize postoperative hypertension. 87 This increase in BP values usually begins 10 to 20 minutes after surgery and can last up to 4 hours. The pathophysiology of POHE in patients previously normotensive is associated with peripheral vasoconstriction, catecholamine release, reduced baroreceptor sensitivity, central adrenergic activation, vasopressin release, stimulation of the renin-angiotensin system with consequent angiotensin II production, release of inflammatory cytokines (IL-6), and sodium retention. All these changes result in vasoconstriction, increase in afterload and SBP/DBP, and tachycardia. If left untreated, postoperative hypertension increases the risk of myocardial ischemia, AMI, APE, stroke, and bleeding, as well as postoperative mortality. 88,89 747