151
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Butalia S, Audibert F, Côté AM, Firoz T, Logan AG, Magee LA, Mundle W, Rey E, Rabi DM, Daskalopoulou SS, Nerenberg KA. Hypertension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy. Can J Cardiol 2018; 34:526-531. [PMID: 29731014 DOI: 10.1016/j.cjca.2018.02.021] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 11/18/2022] Open
Abstract
We present Hypertension Canada's inaugural evidence-based Canadian recommendations for the management of hypertension in pregnancy. Hypertension in pregnancy is common, affecting approximately 7% of pregnancies in Canada, and requires effective management to reduce maternal, fetal, and newborn complications. Because of this importance, these guidelines were developed in partnership with the Society of Obstetricians and Gynaecologists of Canada with the main common objective of improving the management of women with hypertension in pregnancy. Guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children are published separately. In this first Hypertension Canada guidelines for hypertension in pregnancy, 7 recommendations for the management of nonsevere and severe hypertension in pregnancy are presented. For nonsevere hypertension in pregnancy (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 80-109 mm Hg), we provide guidance for the threshold for initiation of antihypertensive therapy, blood pressure targets, as well as first- and second-line antihypertensive medications. Severe hypertension (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg) requires urgent antihypertensive therapy to reduce maternal, fetal, and newborn adverse outcomes. The specific evidence and rationale underlying each of these guidelines are discussed.
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Affiliation(s)
- Sonia Butalia
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
| | - Francois Audibert
- Department of Obstetrics and Gynecology, CHU Sainte Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Tabassum Firoz
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Laura A Magee
- Department of Women and Children's Health, St Thomas' Hospital, London, United Kingdom; School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - William Mundle
- Maternal Fetal Medicine Clinic, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Evelyne Rey
- Division of Obstetric Medicine, Department of Obstetrics and Gynecology, CHU Sainte Justine, Montréal, Québec, Canada
| | - Doreen M Rabi
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Stella S Daskalopoulou
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Kara A Nerenberg
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Medicine, Obstetrics and Gynecology, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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153
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Alanazy MH, Barakeh RB, Asiri A, Edrees MF, Abuzinadah AR, Aljafen BN, Muayqil T. Practice Patterns and Barriers for Intravenous Thrombolysis: A Survey of Neurologists in Saudi Arabia. Neurol Res Int 2018; 2018:1695014. [PMID: 29666704 PMCID: PMC5831958 DOI: 10.1155/2018/1695014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/03/2018] [Accepted: 01/18/2018] [Indexed: 02/04/2023] Open
Abstract
Only a small fraction of patients with acute ischemic stroke receive intravenous thrombolysis (IVT). We sought to assess barriers and practice patterns in using IVT for acute ischemic stroke among neurologists in Saudi Arabia. An electronic survey was sent to all neurologists registered with the Saudi Commission for Health Specialties. A total of 148 (77.5%) neurologists responded. The most common reported barriers for IVT administration were delayed presentation to hospitals (82.4%) and unclear time of symptom onset (50.0%). Only 9.9% of neurologists reported strict adherence to the American Heart Association/American Stroke Association guidelines for IVT administration. The most frequently waived criteria were "minor stroke with National Institutes of Health Stroke Scale [NIHSS] < 5" (49.4%) and "seizure at onset" (45.7%). For the extended 3-4.5-hour window, 18.5% of neurologists reported strict adherence to the four exclusion criteria. The most frequently waived criteria were "age older than 80 years" (53.1%) and "history of both diabetes and prior stroke" (42.0%). In conclusion, most neurologists do not adhere to the IVT exclusion criteria. However, little consensus exists regarding which criteria do not interfere with IVT administration. Barriers to IVT administration were identified and require immediate action by healthcare authorities in Saudi Arabia.
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Affiliation(s)
- Mohammed H. Alanazy
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rima B. Barakeh
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alanood Asiri
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maha F. Edrees
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad R. Abuzinadah
- Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bandar N. Aljafen
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Department of Internal Medicine, King Saud University Medical City and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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154
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Miller EC, Sundheim KM, Willey JZ, Boehme AK, Agalliu D, Marshall RS. The Impact of Pregnancy on Hemorrhagic Stroke in Young Women. Cerebrovasc Dis 2018; 46:10-15. [PMID: 29982254 PMCID: PMC6158089 DOI: 10.1159/000490803] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/11/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Pregnancy is a sex-specific risk factor for causing hemorrhagic stroke (HS) in young adults. Unique physiological characteristics during pregnancy may alter the relative risk for HS in pregnant/postpartum (PP) women compared to HS in other young women. We compared patient characteristics and HS subtypes between young non-pregnant and PP women. METHODS We reviewed the medical records of all women 18-45 years old admitted to our center with HS from October 15, 2008 through March 31, 2015, and compared patient characteristics and stroke mechanisms using logistic regression. RESULTS Of the 130 young women with HS during the study period, 111 were non-PP women, and 19 PP women. PP women had lower proportions of vascular risk factors such as hypertension, prior stroke, and smoking, and a higher proportion of migraine (36.8 vs. 14.4%, p = 0.01). After adjusting for hypertension, smoking, migraine, prior stroke and prior myocardial infarction, PP women had lower odds of having an underlying vascular lesion (OR 0.14, 95% CI 0.04-0.44, p = 0.0009) and a higher proportion of the reversible cerebral vasoconstriction syndrome (RCVS) as cause of their HS. CONCLUSIONS Women with pregnancy-associated HS had fewer cerebrovascular risk factors, lower odds of having -underlying vascular lesions, and higher proportion of -migraine and RCVS compared with similar-aged non--pregnant women. Pregnancy-associated HS appears to represent a unique pathophysiological process, requiring targeted study.
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Affiliation(s)
- Eliza C. Miller
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Kathryn M. Sundheim
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Joshua Z. Willey
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Amelia K. Boehme
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Dritan Agalliu
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA.,Departments of Pathology and Cell Biology and Pharmacology, Columbia University Medical Center, New York, NY, 10032, USA.,Columbia Neuroscience Translational Initiative Center, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, 10032, USA
| | - Randolph S. Marshall
- Department of Neurology, Columbia University Medical Center, New York, NY, 10032, USA
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155
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Swartz RH, Ladhani NNN, Foley N, Nerenberg K, Bal S, Barrett J, Bushnell C, Chan WS, Chari R, Dowlatshahi D, Amrani ME, Gandhi S, Gubitz G, Hill MD, James A, Jeerakathil T, Jin A, Kirton A, Lanthier S, Lausman A, Leffert LR, Mandzia J, Menon B, Pikula A, Poppe A, Potts J, Ray J, Saposnik G, Sharma M, Smith EE, Bhogal S, Smitko E, Lindsay MP. Canadian stroke best practice consensus statement: Secondary stroke prevention during pregnancy. Int J Stroke 2017; 13:406-419. [PMID: 29171360 DOI: 10.1177/1747493017743801] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Canadian Stroke Best Practice Consensus Statement: Secondary Stroke Prevention during Pregnancy, is the first of a two-part series devoted to stroke in pregnancy. This document focuses on unique aspects of secondary stroke prevention in a woman with a prior history of stroke or transient ischemic attack who is, or is planning to become, pregnant. Although stroke is relatively rare in this cohort, several aspects of pregnancy can increase stroke risk during or immediately after pregnancy. The rationale for the development of this consensus statement is based on the premise that stroke in this group requires a specifically-tailored management approach. No other broad-based, stroke-specific guidelines or consensus statements exist currently. Underpinning the development of this document was the concept that maternal health is vital for fetal wellbeing; therefore, management decisions should be based on the confluence of two clinical considerations: (a) decisions that would be made if the patient was not pregnant and (b) decisions that would be made if the patient had not had a stroke. While empirical research in this area is limited, this consensus document is based on the best available literature and guided by expert consensus. Issues addressed in this document include general management considerations for secondary stroke prevention, the use of antithrombotics, blood pressure management, lipid management, diabetes care, and management for specific ischemic stroke etiologies in pregnancy. The focus is on maternal and fetal health while minimizing risks of a recurrent stroke, through counseling, monitoring, and the safety of select pharmacotherapy. These statements are appropriate for health care professionals across all disciplines.
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Affiliation(s)
- Richard H Swartz
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada
| | - Noor Niyar N Ladhani
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada
| | - Norine Foley
- 4 Department of Foods and Nutrition, Western University, London, ON, Canada.,5 workHORSE Consulting Group, London, ON, Canada
| | - Kara Nerenberg
- 6 Department of Medicine, 70401 University of Calgary , Canada
| | - Simerpreet Bal
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada
| | - Jon Barrett
- 1 Sunnybrook Health Sciences Centre, Toronto, Canada.,3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada
| | - Cheryl Bushnell
- 8 Wake Forest Baptist Stroke Center, Wake Forest Baptist Health, Winston Salem, NC, USA
| | - Wee-Shian Chan
- 9 Department of Obstetric General Internal Medicine, 8163 British Columbia Women's Hospital , Vancouver, Canada
| | - Radha Chari
- 10 Department of Medicine & Dentistry, Obstetrics and Gynecology, 215465 University of Alberta , Canada
| | | | - Meryem El Amrani
- 12 Hôpital du Sacré-Coeur de Montréal, Neurology, Montreal, Canada
| | - Shital Gandhi
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,13 Sinai Health System, Toronto, Canada
| | - Gord Gubitz
- 14 Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,15 Department of Medicine (Neurology), Dalhousie University, Canada
| | - Michael D Hill
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Andra James
- 17 Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
| | - Thomas Jeerakathil
- 18 Department of Medicine & Dentistry (Neurosciences), 215465 University of Alberta , Canada
| | - Albert Jin
- 19 Department of Medicine, Queen's University, Canada
| | - Adam Kirton
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Sylvain Lanthier
- 12 Hôpital du Sacré-Coeur de Montréal, Neurology, Montreal, Canada
| | - Andrea Lausman
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,20 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Canada
| | - Lisa Rae Leffert
- 21 Department of Obstetric Anesthesia, 2348 Massachusetts General Hospital , Boston, MA, USA
| | - Jennifer Mandzia
- 22 Department of Clinical Neurological Sciences, Western University, London, ON, Canada
| | - Bijoy Menon
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | - Aleksandra Pikula
- 2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada.,23 Neurovascular Unit, UHN/Toronto Western Hospital, Toronto, ON, Canada
| | - Alexandre Poppe
- 24 Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jayson Potts
- 9 Department of Obstetric General Internal Medicine, 8163 British Columbia Women's Hospital , Vancouver, Canada
| | - Joel Ray
- 3 12366 Faculty of Medicine (Obstetrics and Gynecology), University of Toronto , Canada.,20 Department of Maternal-Fetal Medicine, St. Michael's Hospital, Canada
| | - Gustavo Saposnik
- 2 12366 Faculty of Medicine (Neurology), University of Toronto , Canada.,25 St. Michael's Hospital Stroke Research Unit, Toronto, ON, Canada
| | - Mukul Sharma
- 26 Department of Medicine, Division of Neurology, McMaster University, Hamilton, ON, Canada
| | - Eric E Smith
- 7 Department of Clinical Neurosciences, 70401 University of Calgary , Canada.,16 Calgary Stroke Program, Canada
| | | | - Elisabeth Smitko
- 27 282184 Heart and Stroke Foundation of Canada , Toronto, ON, Canada
| | - M Patrice Lindsay
- 27 282184 Heart and Stroke Foundation of Canada , Toronto, ON, Canada.,28 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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