ABC | Volume 114, Nº4, April 2020

Statement Luso-Brazilian Position Statement on Hypertensive Emergencies – 2020 Arq Bras Cardiol. 2020; 114(4)736-751 POHE occurs in 40 to 80% of the patients undergoing carotid endarterectomy or open cardiac surgery, 57% of the patients undergoing abdominal aortic surgery and 29% of those undergoing peripheral vascular surgery. 90-92 In particular, acute and severe hypertension with SBP elevation > 220 mmHg may occur in 9% of the individuals undergoing carotid endarterectomy. 93 This manifestation, which may be transient, is related to carotid sinus manipulation and may cause hematoma, myocardial ischemia, and cerebral hyperperfusion with consequent neurological damage. 94 Other proposed mechanisms include iatrogenic denervation, 95 decreased baroreflex activity, 96 reduced carotid sinus sensitivity, and increased production of cerebral renin and/or catecholamines. 97,98 HE may also occur after surgical correction of aortic coarctation. The etiology is multifactorial and includes changes in the baroreceptor reflex, activation of the sympathetic system and renin-angiotensin system, and expansion of the extracellular volume. 99 The stimulation of sympathetic nerve fibers located in the middle layer and adventitia of the aortic isthmus has two effects, both resulting in hypertension. Initially, peripheral release of norepinephrine occurs, with consequent vasoconstriction and BP elevation. Next, stimulation of juxtaglomerular cells occurs, releasing renin and promoting additional hypertension. Secondarily, increased renin production causes blood shunting from the mesenteric arteries, thus triggering abdominal symptoms in the so-called post-coarctectomy syndrome. 100 Before initiating antihypertensive pharmacological treatment, reversible causes of postoperative hypertension should be investigated, such as pain, hypoxia, hypercapnia, agitation, bladder distension, and hypervolemia. 101 Proper analgesia and sedation are considered to be requirements before the initiation of antihypertensive therapy. 102 When POHE is present, the distinction between emergency and urgency is mandatory. 1-4 The therapeutic goal is not necessarily to normalize BP but to interrupt the vascular injury and reverse the pathological process. Progressive BP reductions, as reported in the general principles of HE treatment, should be achieved. 1 1. 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