P1499 - “How Low Can You Go”: Profound Hemodynamic Compromise During Colonoscopy Related to Antihypertensive Therapy

Marisa-Nicole Zayat, BS¹, Zeina-Christina Zayat, BS², Marci Drees, BSN, MSNA, CRNA³, Michael Lievens, MD², Estephan Zayat, MD^2
1University of Kansas Medical Center, Kansas City, KS; ²University of Kansas School of Medicine, Wichita, KS; ³Kansas Endoscopy, LLC, Wichita, KS

Introduction: Colonoscopy is a common and safe procedure. Antihypertensives are well-tolerated and widely prescribed. Studies have demonstrated conflicting evidence regarding the benefit of withholding antihypertensive therapy 24 hours before procedures requiring anesthesia, including colonoscopies. We present a case of profound hemodynamic compromise during an otherwise uneventful colonoscopy that we believe is related to antihypertensive therapy.

Case Description/Methods: An active 57-year-old male patient with a history of well-controlled hypertension and dyslipidemia underwent a colonoscopy to evaluate an abnormal digital rectal exam. His medications included olmesartan, hydrochlorothiazide, amlodipine, alfuzosin, and atorvastatin. His pre-procedural blood pressure was 123/79 and heart rate was 66. Within three minutes of propofol administration, his blood pressure dropped to 93/60 with a heart rate of 56. His blood pressure continued to go lower despite retraction of the scope to relieve any vagal stimulation, aggressive fluid resuscitation, multiple doses of phenylephrine, one dose of epinephrine, and one dose of glycopyrrolate. He reached a nadir blood pressure of 66/38 and a heart rate of 67. By the end of the procedure, his blood pressure was 107/53 with a heart rate of 66. The patient denied any chest pain or shortness of breath but was noted to have a blood pressure of 84/58 and a heart rate of 53 thirty minutes after the termination of the procedure. It was decided to admit him to the hospital for cardiovascular monitoring and evaluation. Although antihypertensives were held, he remained hypotensive and bradycardic for 48 hours. His troponin levels did increase, indicating a myocardial infarction complicating his procedure. Electrocardiogram, echocardiogram, and stress test were negative, confirming the absence of structural heart disease and further implicating the antihypertensive medications as a cause.

Discussion: Propofol enables the sustainment of low heart rate despite low blood pressures. The combination of multiple antihypertensive medications and anesthetics may have worked synergistically to create and sustain hemodynamic compromise in our patient. Our case highlights the importance of closely monitoring vital signs during a colonoscopy, especially when using propofol in a patient on multiple antihypertensive medications.


Disclosures:
Marisa-Nicole Zayat indicated no relevant financial relationships.
Zeina-Christina Zayat indicated no relevant financial relationships.
Marci Drees indicated no relevant financial relationships.
Michael Lievens indicated no relevant financial relationships.
Estephan Zayat indicated no relevant financial relationships.


Marisa-Nicole Zayat, BS¹, Zeina-Christina Zayat, BS², Marci Drees, BSN, MSNA, CRNA³, Michael Lievens, MD², Estephan Zayat, MD². P1499 - “How Low Can You Go”: Profound Hemodynamic Compromise During Colonoscopy Related to Antihypertensive Therapy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.