Hypertensive Emergency

Yes, but we're able to see the slides and see that you were okay. Good. So we're going to have a very short discussion on hypertensive emergency. We'll mention a little bit of the definition of what hypertensive emergency is, some etiology that has been proposed because the hypertensive emergency. I'm going to bring management in two parts: general management, like education to any condition that is in the emergency room, and they mention the drugs, that some of the drugs that were used for hypertensive emergency, and just highlight one or two conditions, hypertensive emergencies that you will see in the emergency room.

So the definition of normal blood pressure, as we know, is a blood pressure but it's less than 120, and a diastolic less than 80. Elevated nature is defined as 120 to 129 over greater than 80. Hypertensive emergency, over dramatic look forward, it's not that common; it's in the emergency room about one percent of all ED visits in total; maybe a patient with a hypertensive. Now the definition is usually severe hypertension, a diastolic usually greater than 120, usually in the in the context where there's a sunrise in the blood pressure, but the most important feature is that he must have acute ongoing and mortgage where same time when you seeing this patient. This condition can occur in patients who are usually non-attentive; sometimes these impatients were known to have hypertension. Normal testification as an example is a pregnant female who developed preak and income shot during our pregnancy.

No, can't talk about intensive emergency without breaking another form of severe hypertension, which is a very potential. Now these patients also have elevated blood pressures; they can have systems greater than 120, and they're they also can be great to them and it's still greater than 180 and then the greater than 120. They may or may not present with a mild headache. In these patients, they tend to come for other reasons other than attention, so they usually don't have any features of any inorgan damage, acute and organ damage.

Now how do you manage these students? It's all for debate. Some persons, it may see knee jerking; they try to all these patients' blood pressure, but lowering these blood pressures in these patients aggressively go through at risk because remember these patients are not cute organ damage; they have been a climate test high blood pressure for quite a while, and it is really recommended that this blood pressure should be gradually lowered over days, probably even hours. It's a cute job that we tend to do in patients with intensive emergency, and which means that most of these patients can be managed enough efficient sitting.

Now the actual cost of hypertensive emergency is off a little bit; exactly what caused it. Some purpose has been put together that is a decision in the auto regulatory system. So you know, basically the blood pressure is due to the the pressures in the arteries or their size, and auto relation maintains the blood pressure, but sometimes there's a disruption in that where the blood pressure means only get very high and instead of days of constricting, they may dilate, and this increased flow and blood pressure of course needs to end the fever damage, and we know that the endothetic damage tries calcite inflammatory where Bill of fabrics and edema, and of course those blocks lumens of the arteries and arterials leading extremia because of again, similarly there may be reasons; different areas of the body may go under this constriction triggered; they trigger mechanism is not known, and of course again when you have vasoconstriction, decrease blood flow, hyperprovision lead into ischemia, cell death, and again sugar and inflammatory Cascade, I'm making the situation even worse. These two proposals have really been put forward towards the brain and Arena, but the actual real cause of hypertensive emergencies is really not certain.

Unlike all patients, you must have an idea of what you're going to imagine; you must have a plan, a strategy, but the underlying problem for patients with hypertensive emergency is that their blood pressure is too high and it's causing injury. So of course your your management is get to lower the blood pressure; however, you don't want to make these patients hypertensive, and high potency can be in these patients. What persons are tending to get normal blood pressure, so you may be thinking you're bringing other person's blood pressure to normal levels, but for this patient who has been acclimatized and of course something elevated blood pressures, you're not being kidding hypertensive and hypotension; you know it's not without its risk. Hypotension can cause a stroke, can cause your myocardial infarction, can cause urinal injury. Just to remind you in these patients, especially our chronic Capital participation, the auto regulatory system has been recalibrated at a higher level, so what you think is normal blood pressure for them is actually high potency for them and causing the complications of hypotension.

So how you manage these patients, we're going to talk a little bit about the drugs that we have and the general targeted blood pressure, trying to lower them too, because we're not going to try and make them normal intensive less than 120 systolic less than 80, because that's not what you have these patients. They must have an idea of what you're going to lower the blood pressure to. As a general rule for most conditions, you're trying to lower the blood pressure between 10 to the mean RTL blood pressure, the map between 10 to 20 within the first home, so that's your target, and then a gradual loin over the next 23 hours of five to fifteen percent depending on the condition that you're dealing with. What does that look in absolute value? So you try to get the blood pressure between a 180 120 in the first hour, and then over the next 23 hours you're trying to get them down to a 161 10. There are exceptions to every rule in medicine, and hypertension, hypertensive emergency is is not really different, so just like I mentioned, this may be a great little drop in blood pressure; there are conditions you need to be more aggressive, and there are conditions that you need to more gradual. So gradual, an example of gradual is the patient to take ischemic stroke which we're not offering any intervention for. So in these patients we tend to be more graddling their blood pressure line, while patients who are having a dissection, and yet the section due to their elevated high blood pressure, in these patients you want to remove the shearing forces, so you're actually more aggressive in these patients in low in their blood pressure.

General management of all patients needs justice personal safety. So Covetous taught us, but even before the event of covet, when you're approaching a patient, you need to ensure that the environment is safe. Again, we're not just talking about infectious causes, chemical contamination, the environment that's working is that the light above is going to drop into your head and knock you out; is that the patient is acting a boy stress and aggressive and they were 300 pounds and six foot seven? So situation like that before you approach any patient, you need to ensure that their safety team is always better than individual work, so very possible you use a team that new team approach to get help. A team can do simultaneous things at the same time; somebody can get the history, somebody can touch monitors, somebody can get the necessary invest IV access, start the investigations, access medication, so T Dynamics is far better than individual management. Again, as I said, I'm breaking it down in general management; you always hear about ABC immobilization; hypertensive emergency is no exception to this. What about the person who may have had a a seizure due to their hypertensive encephalopathy and filled without protection? If you don't think about the fact that this person had a fall, on witnessed unprotected fall, the ecosystem in a C-SPAN injury, even though you're thinking some medical condition. So of course you have to ensure that the airway is open and patent. Remember the unresponsive patients, the most commonest reason why they may have area obstruction is your tongue; the other things that we know about like your your vomiters, blood secretions as well, and how you can assess Airway: can the patient talk to you, or the week and talk and speaking clearly, or do you hear features of obstruction such as your gurgling Zone, or do you see features of obstruction, you see the vomitos in the mountain in the nostril or the blood? So of course you may have to start with opening the airway under simple manuscripts such as headsets, Gene lift, or your joy thrust Maneuvers, and of course clearing the airway, the other junks that they may use for the airway to keep it open because the patient is not keeping their ear open and yeah their joints like your oral pharyngeal anywhere in the frontial airway; in some cases you may have to place in a definitive Airway such as your endotracheal tube or lowering a mask or something like that just to keep the airway patent.

B used for breeding and basically assessing the effectiveness of the patient's breathing, so it starts from your look listener feel; is a breed is a person breathing; is it symmetrical to your feelings the abnormalities in the chest; they fall increase give them a chest injury um or they have an effusion, so everything like you look listen and feel the inspection percussion palpitation that you learned in first year clinical medicine; you're checking the rate or the turkey neck; are they not are they normal or what's the saturation; is there breathing effective, and of course with this information you're intervene as as it is necessary. Circulation we know sea circulation, and this is we're trying to gather as much information as possible, so in other words again you're doing this the this um examination of the heart couple reflexes suppose the character the presence their blood pressure the ECG because you need to notice something in our current monitor; you're getting their vitals; you are super parent to manage your patients to put in their large bar accesses start pulling the Bloods because they put in accesses getting ready to give them medication or fluids as needed, so that's your C examining them to see if your features to give an idea of what's going on um what is going on with their heart.

These disability the patient may be confused, boisterous, aggressive; sometimes a lot of times in the emergency room your patient arrives before the history because the patient is not in a state to give the history themselves; they were rushed him by whoever and sometimes it's assessing the patient may give an idea what is something to the patient or not so much the history. So if they are confused, aggressive, they are uptunded, it may indicate that their policy the pathology of course is CNS. The other methods surface disability from your Apple method to your Glasgow comma scale and of course your pupils. D can cover two not just um disability and pupils but also for dextrose glucose patients with a change in mental status whether they are aggressive or uptunded always remember hypoglycemia; they may not necessarily be diabetics; they may have taken something; the nutritional status it is so very common Jamaica's national this is Aki and from the times we do get our patients coming in because of hockey poisoning; you may just get it first please remember your glucose dextrose your glucose; it's a simple bedside test that gives you a lot of information. Exposure of the patient is very important, of course being mindful of modesty and the temperature management of the patient, but sometimes you need to really examine the patient from head to toe, expose them; they've been in stepwise fashion so you examine one area then cover it up back and go on, but you need to examine and that means front back under the arms everywhere because that's where you may get information from your trap Max maybe in between their web spaces and that's the one thing you recognize okay this person may be a drug abuser or something or a tattoo or the medicine patch or something else, so you need to expose the patient; a fully clad patient is not really helping you because you miss serious information and diagnosis on the patients; they need to expose their patients. So of course you will always talk in emergence through my targeted history, my appropriate history and I helped um New Monica can use is your sample history, your signs and symptoms, what brought them in here, what was happening to them, of course allergies because next you know you give them medication that makes it worse or is an allergy I recognizes an allergy, exposure medications of course is very important; I need not to explain that pertinent past medical history, last oral intake and maybe a patient that needs to go to surgery and of course the same LM can use the last L can use the last menstrual cycle for your females of child being age was led up to the event; what was happening where they're upset where they're angry where they're shouting where them did they miss the medication what what was happening what led up to the to their presentation. Information comes from anywhere; there are patients who have in the department especially because remember staff routine that this patient is a poor historian but it's all the older staff members or staff members who are in the department for what maybe the source of information; you may have to make a phone call; you may have to call because he's a co-worker, a Good Samaritan, someone in the bus run the patients in and you find an ID; you recognize that patient is in the system; you may have to call family members or somebody, so the information comes from any source that you need to get the information from to for you for you to be able to manage your patients. Of course in history is going to try and give an idea of what is going on whether it be chest pain, headaches, shortness of breath to give you an idea of where you're going to go with your differentials in your head or you're going to are you going to clot the patient right; it's severe tear into back pain again it may be a history of it in this section patient coming because of worsen shortness of breath our thought now proximal drama distance again you're thinking of pulmonary edema; they may be on medications all them patients then be their medication and they run out of medication but the last medication was two days ago or something are changes in their dose of medication and that gives you an idea of what may be going on with the patient. Of course the investigation is going to be directed by your history and examination and of course you're looking for features of targeted and organ damage and I mean this is just a list of the investigations you may have to utilize; you may use some in some patients may use all in some cases they may only use one or two of these investigations based on a patient the history and examination.

All right, so the treatment of hypertensive emergency is due to parental drugs, and what's the features of these parential drugs? They usually you want them to be titratable, something that you can give in small aliquotes and monitor in a short time their effect, something that is irreversible because remember you're walking a type rope here; you're trying to lower the blood pressure but you're trying to not make them hypertensive; it's a narrow margin you're working with; you're working with a map between 10 to 20 percent; you don't want to you don't want to lower than that but you want some lowering of the blood pressure. Foreign excuse me, initrates, so it's your natural per side and your nitroglycerin. Another vasodilator is a calcium channel blockers and I'll say you dopamine an antagonist. Now the good thing about the dopamine one antagonist defender of the Palm is also good; it's also spares the kidney, so for kidney patients who keep renal impairments Arena pathology this is an idea drug for them because remember low in the blood pressure tends to lower the profusion of the kidneys which can make kidneys um conditions worsens, but this one though it lowers the blood pressure it still Spears the blood flows to the kidneys. You have your adrenergic antagonist; I remember there are different adrenergic crystals in the body that different sections medicine please remember the last medication you've got this one the fellow the pump this one yes this what about it who I was asking a name or the name okay so you are genetic antagonists receptors different different receptors and different organ systems so yeah adrenergic antagonists you can be from your combination beta and Alpha a genetic blocker beta LOL which we use a lot; you may want something more cardiac selectives such as a metopropolol or asthma alone a more beta one antagonist; a general non-specific selector is a phentolamine; it's not used widely; it's using conditions where you have um like refractive hypertension like persons who are having catecholamine withdrawal or um amphetamine overdose. Idealizing is a very old drug; it's more a arterial dilator vasodilator um problems with vasodilators they tend to cause a reflex tachycardia and in some of the conditions we're treating that is that is also um detrimental to the patient as well as hypotension, so sometimes you may have to give a beta blocker along with these drugs to try and prevent this reflex tachycardia because that can also be harmful to the patient. IV version of the instant inhibitor is relax. Now again sometimes in certain conditions healthcare workers may come across a patient that they think is having a hypertensive emergency although in truth most times is the estimate asymptomatic severe hypertensive patients they actually might be dealing with but they're thinking that they're so far from parental medication and that they're trying to help the patient that they may actually give these patients oral medication and communist oral medication I tend to use is um ketamine captopril and nifedipine. Now the probability oral medications you have no control in terms of the rate of absorption, the onset of action, duration of action and the extent of action, so you give these patients these oral medication and you you you are watching them in a situation where you cannot manage them and their blood pressure comes down and you say okay good you do something good and then you send them off; you may even send them home but the medication continues to work because it's long acting so they know go home and the blood pressure still counting to the laws to the reach the point of hypotensive um situation and coming out a stroke or am I even though you think you are doing them good you're actually doing them bad.

Excuse me, I'm sorry, silico talking about some of the hypertensive emergency from neurological cardiac that you may see in the emergency room. So if we talk about the neurological emergency, of course these patients will come in features of CNS pathology but I'd be confused, Delirious, attended aggression; they may come in and give you a history that they're having a headache; they may have blurred visions but of course you so you realize that they're having a CNS problem; no is this like a hypertensive encephalopathy, is this a ischemic event, this is hemorrhagic event; history may help, examination may help, but in truth and facts sorry but in true self actually very differential which one of the conditions that you're really dealing with; you really need you know Imaging and unfortunately that's a weakness not a lot of our health our public systems at this point in time; you really need an urgent emergency neural Imaging in these patients to have an idea exactly what you're dealing with whether it be just an ischemic event or hemorrhagic event. So if we talk about the hemorrhagic events such as the intracerebral Hemorrhage or your subarot Hemorrhage, the management of these patients with hypertensive emergency we know again is to lower the blood pressure. Sorry, I'm just waiting for the siren to pass. Sorry about that [Music]. So we know we need to lower the blood pressure to decrease bleeding, but again just as I said before you don't want to lower too low because this patient needs a bit of high blood pressure to make perfusion to other parts of the brain. So in the intracerebral Hemorrhage what's the goal? You're looking at again you may be aiming that if their blood pressure is between a 220 150 you're trying to lower their blood pressure between a a systolic of 140. Again this is within in the first oil but you have to manage these patients; you have to monitor them as you do so to make sure their situation is not working because they're not tolerating such low blood pressures; if their blood pressure is greater than the 220 then you're not aiming for as low as a 140; you may be aiming for systolic hour 116 said because again remember it's it's not already spacious; it's coming from where their Ultra regulatory threshold is and the fact that you you try not to make them hypertensive so you're targeting maybe a bit different with what you're starting with. Jokes can you you can use from your calcium chat blockers to your um labito loyalty near Ace um medications; they tend not to suggest the nitrites because it tend to increase the intro cerebral blood pressure for the summer night image again the targeting your aim in a map to bring it on the map to to a a 110 map drop the mean out your blood pressure or in a sister like of about a 160 again again it needs to start what the patient is starting with and again the

Similar drugs that you can use. The important thing is whatever drug you're going to use, you need to be familiar with because you need to be comfortable with it. You need to understand its dosing; you need to understand the side effects, how to monitor it, how to reverse it, what you're using. So whatever drugs you're going to use in your armamentarium of medication, whether hypertensive emergency or even antibiotics or anti-hypertensive medication, you really need to understand the properties of what you're using.

One thing to mention: like in a subarachnoid hemorrhage, because they may also use another calcium channel blocker, okay, nimodipine, to prevent vasal spasm. Remember, it is also a calcium channel blocker. One second, sorry, it's also a calcium channel blocker. See, me actually having two agents causing hypotension. Needless to say, we know that these patients ideally are managed in an ICU situation, so you can have close monitoring of these patients with arterial lines to monitor as you're touching with these patients. That's the ideal situation. Unfortunately, sometimes you're not working in the ICU situation.

No ischemic stroke. So this, of course, this is where you have blockage of an artery but not actually the hemorrhage, and the approach may be a little different depending on what you're going to offer the patients. One thing to remember is that again, these patients' autoregulation is impaired at a higher threshold. There are parts of the brain that are dependent on high blood pressure to allow perfusion beyond the obstruction. So you lowering the blood pressure to a normal value, you are actually worsening the area of ischemia, which is called a penumbra. So you need to balance between lowering the blood pressure but still allowing a high enough blood pressure to cut to allow perfusion in the brain.

So most times you'll see a lot of hypertensive patients who are admitted, and you realize nobody is trying to control their blood pressure; they're allowing them to maintain this elevated blood pressure. No, but there are candidates who we lower aggressively. So I don't know if you guys have been exposed yet to the recommendation. It started from the American Heart Association, but the recommendation pertaining to ischemic stroke is that if these patients get to an institution, let alone emergency neural imaging was an M.C.T. scan, that offers thrombolytics, fibrinolytics, or embolectomy, these patients within a time frame can be offered this therapy that can either decrease the effect of the ischemic stroke or even reverse the effects of ischemic stroke.

So what I mean: from the time of the onset of the symptoms, so let's say it's 5:40, and the person's developing a feature of a stroke, and the features of a stroke can vary from slurred speech, loss of use, whatever, confusion, and it is noted, the time is noted. This patient has a window of three and a half hours to four hours in some institutions to get investigations done for a decision to be made, either meet the fibrinolytic criteria, be given fibrinolytics that can remove the clot that is blocking the artery to improve their situation. Some persons get full recovery, some persons get partial recovery, but of course, recovery is better than no recovery at all, but it's time-sensitive in these patients. You need their blood pressure to be lowered because we know there is fibrinolytic-increased risk of hemorrhage. So, of course, these patients' blood pressure needs to be lowered and maintained at this lower level, but at least for 24 hours after they give them the thrombolytics.

However, the patients may not reach criteria for thrombolytics, whether it's not offered, whether they're beyond the time period, whether they didn't meet the fragmented checklist, or they chose not that option because when they hear about the risk versus the benefit, they choose not to. But these patients are not offered thrombolytics, fibrinolytics, extremolytics, or even embolectomy. So in these patients' blood pressure, it tends to leave them at a higher level, higher, gradually lower them instead. So you're cautiously lower their blood pressure by the mean arterial blood pressure of 10 to 15 over the next 24, over 24 hours. Again, the drugs that you choose is what's available in the institution and what you're comfortable with, so it can again be from your labetalol, the calcium channel blockers. Nimodipine may also be used, but again, it's not a favorite drug, but if it's what you have to use, you don't have a choice because it tends to affect, um, platelet function.

Hypertensive encephalopathy: the patient's clinical features, features may be the same, but in this case, is due to the effects of the high blood pressure, not due to a hemorrhage or a blockage of the artery, but they also benefit from lowering of their blood pressure. Again, your imaging would have a role in the ischemic and hemorrhage in these patients, and then you'll be giving them the medication to lower their blood pressure. In this patient, you're aiming for the mean arterial blood pressure of 10 to 15 reduction in the first hour and then over the next 2-3 hours, no more than 25 percent of the mean arterial blood pressure. Your drug of choice, again, again, it can vary from any other group, any other categories.

So another common hypertensive emergency is left ventricular dysfunction. If these are the patients who presented with pulmonary edema or you can also have their acute coronary syndrome with their extremely elevated high blood pressure, in these patients, a drug of choice, so is usually a loop diuretics and your nitrites to lower these patients' blood pressure. You don't use hydralazine in these patients because that increases the tachycardia and increases the work of the heart, and beta-blockers because they decrease the contractility of the heart, tend not to use these as well. The aim again is the same: mean arterial blood pressure reduction of 10 to 15 within the first hour. Sorry.

Some renal emergency, like your acute hypertensive nephrosclerosis, um, again, features of organ damage in these persons, you have your microscopic hematuria, elevated BUN and creatinine levels. These patients, you tend to use your fenoldopam if you have it or your ACE inhibitors and your loop diuretics in this section. As I said before, because of the shearing force of the high blood pressure, you want to lower that blood pressure aggressively, but again, remember, vasodilators lowering blood pressure is going to cause reflex tachycardia, so it may have to give them a beta-blocker first to slow the heart rate, which will also lower the blood pressure, and then you can use your vasodilators, um, to, to take your nitrates or your calcium channel blockers to lower the blood pressure to decrease the shearing force over these patients. And patients who can't tolerate beta-blockers, your calcium channel blockers are is a, it's a good, it's a good alternative.

You have rare conditions wherein patients may have been using an older version of hypertensive medication such as clonidine, it's very rare, or they may be taking drugs that they're not supposed to, and the sudden withdrawal of these medications cause or reflex sympathetic overactivity and hypertension, or the cocaine users. These patients, they can use their phentolamine, which is a non-selective, um, blocker or your nitrates such as your nitroprusside. In a pregnant patient with pre-eclampsia and eclampsia, um, use your IV labetalol or your hydralazine. The patient, you'll see that we can send on these patients are more into them in a hospital with oral medication, but that is after lowering their blood pressure with a parenteral medication under, in hospital, for the crisis, and they can use oral medication such as your long-acting nifedipine.

So I'm going to just show you two cases that present, hopefully it will help with the discussion. So the first case we had, these cases are before COVID, so they're shortness of breath, we were not thinking about COVID. The first case was a 70-year-old female. She had worsening shortness of breath in the morning presentation. Her background history or other risk factors: just hypertension, shows diabetic, Joseph, having asthma. She'll come in with a history of productive cough, why it's beautiful. She was known to have bilateral leg swelling, but no history of fever. Examination one: she was noted that she had a pitting edema and she had elevated, um, JVP. Examination of chest: she had crackles bilaterally and occasional rhonchi. Our writers, the nurses obtained, realize she's afraid but not greatly so. What shows hypoxemic, however, the monitor that we're using was not detecting the blood pressure; it was cyclical this time and it was giving an error, and a decision was made to actually do it manually, but a nurse actually did the manual blood pressure, just realized that she has extremely elevated blood pressure. The systolic was still over 300 and the diastolic was greater than 150. So she was assessed as a hypertensive emergency with left ventricular failure. The objective, then, of course, we started our ABCs. She got her oxygen, she got her continuous monitor because she got IV access, in, um, she even got her arterial tube or kept ketopin, and the plan was to lower her mean arterial blood pressure by 50, um, by 25 percent over the first hour, which will be decreasing the MAP to about 150. The MAP before was calculated as 200, and so it was aimed to lower them up to 150. The drugs used were the loop diuretics and the IVGT and IV nitrates, and this was titrated on while monitoring our blood pressure as we go on, our clinical condition. So after the hour, we finally got our blood pressure down to a 204 over 123 and a MAP of 150. Clinically, the patient had improved; of course, she wasn't going to the woods, but she was able to converse a little better, should now start into diuretics, and she was able to speak a little better.

The second case, sorry, was a 56-year-old gentleman. He couldn't provide his history due to, say that he came in, his sister and was his brother. He presented because he had acute shortness of breath that night. He had chest pains and diaphoresis. Is right because, as you can see, he was tachycardic, hypertensive, and hypoxemic. Background history from a sample is known to be hypertensive, but unfortunately, like a lot of our Care Bear meals, he was non-compliant with his medication. He didn't even know his medication. Examination-wise, he was in respiratory distress, showing features of cyanosis. He had pedal edema. He wasn't able to speak. He had bilateral crackles. His ECG, as I don't know if you can appreciate ECG from where you are, but he had left axis deviation, he had Q waves in V1, V2, right, and he had ST segment elevation in V1, V2, V3, V4. Okay, oops, I just happened, what just happened. Okay, all right, sorry. Okay, so he was assessed as the French cafeinum and acute STEMI, I mean, acute coronary syndrome STEMI. ABCs applied, and his attempt to lower his blood pressure, starting it was started with the nitrites and the loop diuretics. However, that was not bringing down the blood pressure. Calcium channel blockers were added. Hydralazine, though by pure definition, is contraindicated in this gentleman, but after he's got in the nitrites, he's gotten the loop diuretics, and he's gotten calcium channel blockers, his blood pressure was still very difficult to bring down, so the hydralazine was added along as well. The aim also decreases mean arterial blood pressure to about 170. It, please, blood pressure did come down to bring it down, um, he was clinically improved, he was able to speak more clearly, his saturation improved, and he was then treated by forgiveness, respect, and there was even changes in his ECG with the lower blood pressure, but given his risk factors, it still wasn't decided to give a metallic, which would be the thrombolytics for his acute, for his STEMI. For overall, the gentleman needed both nitrites, both calcium channel blockers, loop diuretics, and hydralazine to be able to bring down his blood pressure. When his blood pressure came down, the other treatments for his acute coronary syndrome were added in terms of his aspirin, his clopidogrel, and his heparin. And that's it. So far, any questions? Yeah, that's it. Any questions? All right, do you want to log off yet? Let me just take a picture of the, um, register, please.