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Three Part Question

In [an adult with aortic dissection accompanied with hypertensive crisis] does [nicardipine hydrochloride] improve the [blood pressure control, morbidity or mortality]?

Clinical Scenario

A 55-year-old male patient came to the emergency department with the symptoms of acute onset of severe chest pain with radiation to the back, cold sweating, and nausea. He had mild shortness of breath and his pain was most severe at onset. Physical examination revealed blood pressure: 210/120mmHg, heart rate: 101/min, respiratory rate: 20/min (SpO2 97% at room air), irregular heart beat without murmur, and clear breathing sound over the bilateral lung fields. The electrocardiogram (ECG) revealed atrial fibrillation with rapid ventricular response. Chest computed tomography showed a dissecting aortic aneurysm, from the descending thoracic aorta to the left common and external iliac artery. Therefore, a clinical diagnosis of aortic dissection, Stanford B was made. We wondered whether nicardipine was suitable to control his blood pressure and improve the outcome.

Search Strategy

Medline 1987 to April 2010 using the OVID interface and Cochrane Library.

Medline:[(exp Aneurysm, Dissecting)] or [(exp Aortic Aneurysm) ] AND [(exp Nicardipine) or (nicardipine.mp) or (perdipine.mp)] limited to human.
Cochrane Library: [Nicardipine]

Search Outcome

18 papers were found. 2 of them were relevant to the topic of interest (Table)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Takaba T et al. 1995 Japan	20 patients (range, 40-79 years) with acute aortic dissection. Nicardipine was infused continuously at a rate of 0.35～8.3μg/kg/min.	Cohort study	SBP and DBP before and during nicardipine infusion	SBP: Before nicardipine: 174±21mmHg After nicardipine: 136±14mmHg (P<0.001). DBP: Before nicardipine: 82±18mmHg After nicardipine: 65±17mmHg (P<0.01).	Small number of patients. No control group. Short follow-up period. Patient outcomes are not clear.
			Heart rate before and after nicardipine infusion	Before nicardipine: 85±22/min After nicardipine: 82±24/min (P= NS).
			Time needed to decrease the blood pressure level	30 minutes
Kim KH et al. 2002 Korea	31 patients (range, 29 – 89 years) with acute aortic dissection. Nicardipine was infused continuously at a rate of 2~30 mg/h.	Cohort study	Blood pressures at baseline and on the third day of the study	Baseline SBP: 147 ± 23mmHg DBP: 82 ± 18mmHg MBP: 104 ±18mmHg On the third day of the study SBP: 119 ± 12mmHg DBP: 69 ± 9mmHg MBP: 86 ± 8mmHg (P < 0.05).	Small number of patients. No control group. Short follow-up period. Concomitant use of other anti-hypertensive agents.
			Time needed to reach the target blood pressure level	25.6 ± 13.5 (15 – 60) minutes

Comment(s)

Aortic dissection is a frequently fatal hypertensive emergency. Therefore, prompt anti-hypertensive therapy and maintenance of a systolic blood pressure of < 120mmHg in patients with acute aortic dissection is mandatory. Calcium channel blocker (CCB) is used popularly as an anti-hypertensive medication. However, CCB is not commonly used in blood pressure control for acute aortic dissection because there are concerns about the reflex tachycardia induced by CCB. Nicardipine hydrochloride is a parental calcium channel blocker antihypertensive agent currently used worldwide for hypertensive emergency. In the two cohort studies that were related to nicardipine hydrochloride in the treatment of hypertensive emergency in acute aortic dissection, it was reported that nicardipine hydrochloride has a rapid and beneficial effect on decreasing blood pressure. But there are many quality issues and concerns about patient outcomes. Thus, randomized control trials are needed to clarify the effectiveness and safety of nicardipine hydrochloride in the treatment of hypertensive emergency in acute aortic dissection.

Editor Comment

DBP, diastolic blood pressure; MBP, mean blood pressure; NS, not significant; SBP, systolic blood pressure.

Clinical Bottom Line

Nicardipine hydrochloride might be an effective treatment for hypertensive emergency. However, for patients with aortic dissection, randomized control trials are needed to clarify the role of nicardipine hydrochloride in the treatment of hypertensive emergency in those patients.

References

1. Takaba T. Yokokawa H. Moriyasu K. Matsuo Y. Nishikawa T. Kataoka D. Antihypertensive therapy using nicardipine hydrochloride in the treatment of aortic aneurysm. Kyobu Geka - Japanese Journal of Thoracic Surgery 1995;48(4):290-4
2. Kim KH. Moon IS. Park JS. Koh YB. Ahn H. Nicardipine hydrochloride injectable phase IV open-label clinical trial: study on the anti-hypertensive effect and safety of nicardipine for acute aortic dissection. J Int Med Res 2002;30(3):337-45