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Blood pressure

management in stroke
Author :
Ritvij Bowry, MD
Digvijaya D. Navalkele, MD
MPH Nicole R. Gonzales, MD
Introduction
The relationship between hypertension
and stroke is dynamic and multi
faceted. Be it in the context of
managing ischemic or hemorrhagic
stroke, selecting an appropriate
bloodpressure (BP) agent involves
integration of several issues that must
be recognized in order to formulate an
effective strategy for BP control.
Blood pressure, ischemic stroke,
and thrombolysis
O More than 60% of patients with acute ischemic
stroke (AIS) elevated BP (within 1 hour of
symptom onset)
O Elevated BP thrombolytic eligibility and has been
associated with delay in administration of IV tissue
plasminogen activator (IV tPA).
O Timely management of elevated BP is crucial when
patients are otherwise eligible for IV tPA
O The need for prethrombolytic BP goal is 185/110
mmHg
O If BP goal not achieved tPA may be even
withheld Poorer clinical outcome in SICH
O To reduce BP proficiently, agents and continous
infusions could be used
O Aggresively reducing BP to <185/110mmHg with BP
agents safe for patients eligible for TPA (within 3
hours of symptoms)
O If intra arterial (IA) lysis with tPA is planned BP
target <180/100mmHg
O IA recanalization as monotherapy reduce 10-20%
O IA + tPA <180/105mmHg target of BP
O Systolic BP >140mmHg targeted, if below the
treshold it will lead into a poor neurologic outcome
O If complete recanalization is achieved Goal BP
120-140mmHg (lowering the risk of reperfusion
hemorrhage)
O It is reasonable to maintain SBP up top
185mmHg for 24-48 hours (to augment
collateral blood flow & clear emboli from
istal vasculature)
BP must be optimized to
minimize the rate of
symptomatic intracranial
hemorrhage, reperfusion injury,
and promote adequate cerebral
perfusion
BP and Ischemic Stroke When
Thrombolysis is not an option
O If BP 220/120mmHg reducing 15%
is the reccomendation
O Antihypertensive therapy is routinely initiated
within 24 hours after AIS
O BP control beyond 15 hours from onset of an
IS may have a little effect on the clinical
outcome
O A management strategy must ensure a
patients neurologic stability
Specific Goals for Specific
Conditions
O Small Vessel disease
Goal of SBP <130mmHg vs range of 130-
140mmHg for at least 2 weeks after
confirmed with an MRI Reduce all types of
stroke
O Intra cranial atherosclerosis
Goal SBP <140 or <130 in diabetes, LDL
<70, dual antiplatelet therapy with aspirin
and clopidogrel for 90 days & lifestyle
modifications fewer cerebrovascular events
Acute Reduction of BP in ICH is Safe

O Elevated BP after ICH is not only


predictive of outcome but is
associated with recyrent
hemorrhage.
O SBP range 130-140mmHg supported
the safety of an intensive BP
lowering strategy and showed a
reduction of hematoma enlargement
at 24 and 72 hours (when treatment
was initiated within 6 hours of
symptoms onset in ICH)
The curent American Heart
association reccomendations
endorse the safety of acutely
lowering SBP to 140mmHg in
patiens with ICH presenting
with SBP of 150-220mmHg
Antihypertensive Agents in Stroke
O Sodium nitropruside not an ideal agent
for acute reduction of BP
O Hydralazine used frequently for acute
reduction, could lead into myocardial injury
due to its effect of tachycardia
O Nicardipine indicating a reliable dose
response.
Five New Thing
O Patients who present with acute ischemic
stroke and are otherwise eligible for IV tPA
(except for severely elevated BP) can
become thrombolytic candidats with rapid
and efficient BP treatment
O When thrombolysis is not an option, acute
management of BP is a balancing act
between maintaining cerebral prefusion
nd avoidng systemic adverse events due
to persistently elevated BP
O In the acute setting of ICH, rapidly
lowering BP to <140/90mmHg is safe and
may be associated with improved
radiographic and clinical outcomes.
O In the hyperacute setting of both ischemic
and hemorrhagic stroke, initioation of
continuous IV administration of newer
agents may achieve treatment goals
rapidly.
O In the subacute setting of ischemic stroke,
there may not be a need to rapidly bring
BP down to the targeted secondary stroke
prevention range.
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