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MANAGEMENT OF HYPERTENSION IN STROKE PATIENT
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Dr. Shahin Akter NipaMD (Phase A) Resident , Internal
Medicine Chittagong Medical College &
Hospital
GOALS OF BP MANAGEMENT:
1. Ensure adequate cerebral perfusion2. Prevent intracranial bleeding3. Avoid exacerbation of cerebral edema
ACUTE ISCHEMIC STROKE
Acute transient blood pressure elevation occurs after stroke that lasts days to weeks.
Autoregulation of cerebral circulation is impaired in ischemic
cerebral tissue
Higher arterial pressure may be required to
maintain cerebral blood flow.
Sudden and profound
reduction of BP
Insufficient perfusion in
areas already affected
Neurological decline
Unless there is heart failure, MI, renal failure, evidence of hypertensive encephalopathy or aortic dissection blood pressure should not be lowered in first week.
BP often returns towards patient’s normal level within first few days.
WHEN TO START ANTIHYPERTENSIVE?
IF PATIENT IS INELIGIBLE FOR THROMBOLYSIS:
Antihypertensive is only recommended if systolic BP>220 mmHg or diastolic BP >120 mmHg
IF ELIGIBLE FOR THROMBOLYSIS:BP should be <185/110 mmHg before starting thrombolysis
After administration of fibrinolytic drug BP must be strictly
maintained <180/105mmHg
IF FAILURE TO CONTROL BP:
Increased chance of
intracranial haemorrha
ge
Poor functional outcome
DRUGS: IV Labetalol or esmolol
Nicardipine –continuous infusion
Sodium nitroprusside(when diastolic BP >
140mmHg)
Nicardipine
•Initial 5 mg /hour.•Titrate by 2.5 mg/h 5 min -15 interval.
Labetalol
• 2 mg/min up to 300 mg or
• 20 mg over 2 min, then 40-80 mg at 10 min interval upto 300 mg total
• Initial: 0.3 microgm/kg/min
• Maximum:10microgram/kg/min
• Usually 2-4 microgram/kg/min
Nitropruside
• Initial 80-500 mcg/kg over 1 min then,
• 50-300 mcg /kg/min
Esmolol
OBJECTIVES OF TREATMENT:
Reduction of BP 10 -
15%
After stroke, combination therapy with an
ACEI and
a diuretic reduce recurrent stroke.Target BP <130/80mmHg
Intracerebral Haemorrhage
Elevated BP is very common in intracerebral haemorrhage.
Because variety of factors including stress, pain, increased ICP and premorbid acute or persistant elevation in BP
High SBP (MAP >110 mmHg or systolic >160mmHg) is associated with -greater haematoma expansion, -exaggerate cerebral edema, -neurologic deterioration and -death.
Areas of hypoperfusion are frequently present around parenchymal haematoma.
Aggressive BP reduction could precipitate ischemia in these regions.
IF Systolic BP >180 and Diastolic BP >130 mmhg
WHEN TO START ANTIHYPERTENSIVES:
I
TARGET:
SBP<160 mmHg , MAP <110 mmHg
Current evidence indicates :
Early intensive BP lowering (systolic BP target < 140 mmhg) is safe and surviving patients show modestly better functional recovery
Observational studies with advanced neuroimaging have shown no significant ischemic penumbra in ICH with perihematomal rim of low attenuation seen on CT being related to extravasated plasma.
The major CCB drugs are used less often because of reports of adverse effects on intracranial pressure.
SUBARACHNOID HAEMORRHAGE
ACUTE ANEURYSMAL SAH
Target systolic BP<160mmHg, until ruptured aneurysm is secured in order to prevent rebleeding
After aneurysm is secured BP should not be lowered as increased risk for delayed ischemia from vasospasm
REFERENCES:1. Bradley’s Neurology in Clinical Practice 7th Edition
2. Adam’s &Victor’s Principles of Neurology 10th Edition
3. Harrison’s Principles of Internal Medicine 19th Edition
4. AHA/ASA Guideline for the Management of Spontaneous Intracranial Hemorrhage , July 2015
5. AHA/ASA Guideline for the Early Management of Patients with Acute Ischemic Stroke , 2013