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Zaki HA, Lloyd SA, Elmoheen A, Bashir K, Elsayed WAE, Abdelrahim MG, Basharat K, Azad A. Antihypertensive Interventions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Evaluating Clinical Outcomes Through an Emergency Medicine Paradigm. Cureus 2023; 15:e47729. [PMID: 38021612 PMCID: PMC10676241 DOI: 10.7759/cureus.47729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
High blood pressure (HBP) is usually prominent after the onset of acute ischemic stroke (AIS). Although previous studies have found that about half of patients with AIS have a background of hypertension, there is no clear etiology for HBP in AIS. The literature reveals discrepancies in the relationship between HBP and clinical outcomes of AIS, pointing toward the contested effect of blood pressure (BP) reduction clinical outcomes. Thus, the potential benefits and hazards of HBP treatment were explored in the context of clinical outcomes after AIS. An electronic database and a manual search were carried out to identify all the articles related to this topic and published between 2000 and January 2023. The Review Manager software was also used to perform the meta-analysis and quality appraisal. In analyses related to patients not treated with reperfusion therapies, mortality, and dependency outcomes were categorized as short-term (<3 months) or long-term (≥3 months). Our search strategy yielded 2459 articles, of which only 15 met the inclusion criteria. The results of our meta-analysis demonstrate that in patients not treated with reperfusion therapies, BP lowering had no significant impact on either short-term or long-term mortality (risk ratio (RR): 1.18; 95% confidence interval (CI): 0.81-1.73; p = 0.39, and RR: 1.04; 95% CI: 0.77-1.40; p = 0.81, respectively) and dependency (RR: 1.12; 95% CI: 0.97-1.30; p = 0.11, and RR: 0.98; 95% CI: 0.90-1.07; p = 0.61, respectively). Furthermore, BP lowering prior to reperfusion showed no significant effect on mortality (RR: 0.7; 95% CI: 0.23-2.26; p = 0.58), but it did significantly reduce the risk of dependency (RR: 0.89; 95% CI: 0.85-0.94; p < 0.00001). When the dataset was restricted to patients who had successful reperfusion, intensive BP lowering (target systolic BP <120 mmHg) was found to increase the risk of dependency (RR: 1.23; 95% CI: 1.09-1.39; p = 0.0009). In addition, BP reduction had an insignificant effect on the risk of recurrent strokes and combined vascular events (RR: 1.00; 95% CI: 0.54-1.84; p = 1.00, and RR: 0.99; 95% CI: 0.70-1.41; p = 0.95, respectively). Lowering BP in patients not treated with reperfusion therapies is not beneficial in reducing the risk of either short or long-term mortality and dependency. However, BPR before reperfusion reduces the risk of dependency, while aggressive BPR (target systolic blood pressure (SBP) <120 mmHg) after successful reperfusion increases the risk of dependency. Therefore, we recommend BPR as early as possible for patients undergoing reperfusion therapies but suggest against aggressive BPR in patients who have undergone successful reperfusion.
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Affiliation(s)
- Hany A Zaki
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | | | - Amr Elmoheen
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | - Khalid Bashir
- Medicine, Qatar University, Doha, QAT
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| | | | | | | | - Aftab Azad
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT
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Rafaqat S, Khalid A, Riaz S, Rafaqat S. Irregularities of Coagulation in Hypertension. Curr Hypertens Rep 2023; 25:271-286. [PMID: 37561240 DOI: 10.1007/s11906-023-01258-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW This review article summarizes the role of coagulation in the pathogenesis of hypertension. It specifically focuses on significant factors and markers associated with coagulation, including D-dimer, fibrinogen and fibrin, prothrombin, P-selectin, soluble urokinase plasminogen activator receptor, thrombomodulin, tissue factor, tissue plasminogen activator, von Willebrand factor, β-thromboglobulin, and Stuart-Prower factor. RECENT FINDINGS D-dimer levels were elevated in hypertensive individuals compared to healthy controls, and the levels increased with the severity of hypertension. These findings indicate that increased coagulation activity of fibrin plays a role in the development of thromboembolic complications in hypertensive patients. Additionally, both fibrinogen levels and D-dimer levels displayed a positive correlation with the duration of hypertension, suggesting that these biomarkers were positively associated with the length of time an individual had been hypertensive. Increased systolic and diastolic blood pressures have been linked to higher levels of prothrombin time and activated partial thromboplastin time in individuals with hypertension as well as those with normal blood pressure. Also, the presence of P-selectin, produced by activated platelets and endothelial cells during angiotensin II stimulation, played a role in the development of cardiac inflammation and fibrosis associated with hypertension. Moreover, the change in systolic blood pressure was associated with baseline soluble urokinase plasminogen activator receptor (suPAR) in hypertensive participants, and the change in suPAR levels was associated with the development of hypertension. Moreover, it was observed a decrease in thrombomodulin expression in the placenta of preeclamptic patients, suggesting its potential involvement in placental dysfunction, possibly driven by an imbalance in angiogenic factors. Tissue factors and autophagy might have significant implications in the pathogenesis of chronic thromboembolic pulmonary hypertension, particularly in the context of vascular remodelling. Likewise, ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) might be a promising biomarker for the early detection of pulmonary arterial hypertension and the von Willebrand factor is a candidate prognostic biomarker. The arterial β-thromboglobulin levels were significantly lower than venous levels. This article concludes that D-dimer, fibrinogen and fibrin, prothrombin, P-selectin, soluble urokinase plasminogen activator receptor, thrombomodulin, tissue factor, tissue plasminogen activator, von Willebrand factor, and β-thromboglobulin are important factors involved in the pathogenesis of hypertension.
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Affiliation(s)
- Saira Rafaqat
- Department of Zoology (Molecular Physiology), Lahore College for Women University, Lahore, Punjab, Pakistan.
| | - Amber Khalid
- Department of Zoology, Lahore College for Women University, Lahore, Punjab, Pakistan
| | - Saira Riaz
- Department of Environmental Science, Lahore College for Women University, Lahore, Punjab, Pakistan
| | - Sana Rafaqat
- Department of Biotechnology (Human Genetics), Lahore College for Women University, Lahore, Punjab, Pakistan
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Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, Gąsecki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:XLVIII-LXXXIX. [PMID: 34780578 PMCID: PMC8370078 DOI: 10.1177/23969873211012133] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/05/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.
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Affiliation(s)
- Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dariusz Gąsecki
- Department of Adult Neurology, Medical University of Gdańsk, Gdańsk, Poland
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Lisa S Manning
- Department of Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Comparative effects of intensive-blood pressure versus standard-blood pressure-lowering treatment in patients with severe ischemic stroke in the ENCHANTED trial. J Hypertens 2020; 39:280-285. [PMID: 33031175 DOI: 10.1097/hjh.0000000000002640] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Limited data exist on the optimum level of SBP in thrombolyzed patients with acute ischemic stroke (AIS). We aimed to determine the effects of intensive blood pressure (BP) lowering, specifically in patients with severe AIS who participated in the international, Enhanced Control of Hypertension and Thrombolysis Stroke Study. METHODS Prespecificed subgroup analyzes of the BP arm of Enhanced Control of Hypertension and Thrombolysis Stroke Study, a multicenter, partial-factorial, open, blinded outcome assessed trial, in which 2227 thrombolysis-eligible and treated AIS patients with elevated SBP (>150 mmHg) were randomized to intensive (target 130-140 mmHg) or guideline-recommended (<180 mmHg) BP management. Severe stroke was defined by computed tomography or magnetic resonance angiogram confirmation of large-vessel occlusion, receipt of endovascular therapy, final diagnosis of large artery atheromatous disease, or high (>10) baseline neurological scores on the National Institutes of Health Stroke Scale. The primary efficacy outcome was death or any disability (modified Rankin scale scores 2-6). The key safety outcome was intracranial hemorrhage (ICH). Treatment effects estimated in logistic regression models are reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS There were 1311 patients [mean age 67 years; 37% female; median baseline National Institutes of Health Stroke Scale of 11 (range 6.0-15.0)] with severe AIS. Overall, there was no significant difference in the primary outcome of death or disability. However, intensive BP lowering significantly increased mortality (OR 1.52, 95% CI 1.09-2.13; P = 0.014) compared with guideline BP lowering, despite significantly lowering clinician-reported ICH (OR 0.63, 95% CI 0.43-0.92; P = 0.016). CONCLUSION Intensive BP lowering is associated with increased mortality in patients with severe AIS despite lowering the risk of ICH. Further randomized trials are required to provide reliable evidence over the optimum SBP target in the most serious type of AIS. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01422616.
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Bushnell C, Howard VJ, Lisabeth L, Caso V, Gall S, Kleindorfer D, Chaturvedi S, Madsen TE, Demel SL, Lee SJ, Reeves M. Sex differences in the evaluation and treatment of acute ischaemic stroke. Lancet Neurol 2019; 17:641-650. [PMID: 29914709 DOI: 10.1016/s1474-4422(18)30201-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
Abstract
With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.
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Affiliation(s)
- Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lynda Lisabeth
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stacie L Demel
- Department of Neurology & Ophthalmology and Pharmacology & Toxicology, Michigan State University, East Lansing, MI, USA
| | - Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Mathew Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
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Dong Q, Dong Y, Liu L, Xu A, Zhang Y, Zheng H, Wang Y. The Chinese Stroke Association scientific statement: intravenous thrombolysis in acute ischaemic stroke. Stroke Vasc Neurol 2017; 2:147-159. [PMID: 28989804 PMCID: PMC5628383 DOI: 10.1136/svn-2017-000074] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 12/30/2022] Open
Abstract
The most effective medical treatment for acute ischaemic stroke (AIS) is to offer intravenous thrombolysis during the ultra-early period of time after the onset. Even based on the Consensus of Chinese Experts on Intravenous Thrombolysis for AIS in 2012 and 2014 Chinese Guidelines on the Diagnosis and Treatment of AIS, the rate of thrombolysis for AIS in China remained around 2.4%, and the rate of intravenous tissue plasminogen activator usage was only about 1.6% in real world. The indication of thrombolysis for AIS has been expanded, and contraindications have been reduced with recently published studies. In order to facilitate the standardisation of treating AIS, improve the rate of thrombolysis and benefit patients who had a stroke, Chinese Stroke Association has organised and developed this scientific statement.
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Affiliation(s)
- Qiang Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital affiliated to Fudan University, Shanghai Shi, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Anding Xu
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Yusheng Zhang
- Department of Neurology and Stroke Center, First Affiliated Hospital, Jinan University, Guangzhou Shi, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing, China
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Affiliation(s)
- Urs Fischer
- From the Department of Neurology, University Hospital Bern and University of Bern, Switzerland.
| | - Heinrich P Mattle
- From the Department of Neurology, University Hospital Bern and University of Bern, Switzerland
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Nathaniel TI, Cochran T, Chaves J, Fulmer E, Sosa C, Yi S, Fredwall M, Sternberg S, Blackhurst D, Nelson A, Leacock R. Co-morbid conditions in use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke. Brain Inj 2016; 30:1261-5. [DOI: 10.1080/02699052.2016.1186840] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Demaerschalk BM, Kleindorfer DO, Adeoye OM, Demchuk AM, Fugate JE, Grotta JC, Khalessi AA, Levy EI, Palesch YY, Prabhakaran S, Saposnik G, Saver JL, Smith EE. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke 2016; 47:581-641. [DOI: 10.1161/str.0000000000000086] [Citation(s) in RCA: 442] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose—
To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
Methods—
Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
Results—
After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
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Darger B, Gonzales N, Banuelos RC, Peng H, Radecki RP, Doshi PB. Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke. West J Emerg Med 2015; 16:1002-6. [PMID: 26759644 PMCID: PMC4703175 DOI: 10.5811/westjem.2015.8.27859] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/26/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction The purpose of this study was to assess safety and efficacy of thrombolysis in the setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP control prior to thrombolysis. Methods We performed a retrospective review of patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) between 2004–2011. We compared the outcomes of patients treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome was efficacy, determined by functional status at discharge, and in-hospital deaths. Results Of 427 patients included in the analysis, 89 received aggressive BP control prior to thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis. Patients requiring BP control had more severe strokes, with median arrival National Institutes of Health Stroke Scale of 10 (IQR [6–17]) in patients not requiring BP control versus 11 (IQR [5–16]) and 13 (IQR [7–20]) in patients requiring standard and aggressive BP lowering therapies, respectively (p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no statistically significant differences in adverse events between the three groups (P>0.10). Conclusion We observed no association between BP control and adverse outcomes in ischemic stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute the safety of aggressive BP control prior to thrombolysis.
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Affiliation(s)
- Bryan Darger
- University of Texas Medical School at Houston, Houston, Texas
| | - Nicole Gonzales
- University of Texas Health Science Center at Houston, Department of Neurology, Houston, Texas
| | - Rosa C Banuelos
- University of Texas Medical School at Houston, Houston, Texas
| | - Hui Peng
- University of Texas Health Science Center at Houston, Department of Neurology, Houston, Texas
| | - Ryan P Radecki
- University of Texas Health Science Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - Pratik B Doshi
- University of Texas Health Science Center at Houston, Department of Emergency Medicine, Houston, Texas
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McNett M, Koren J. Blood Pressure Management Controversies in Neurocritical Care. Crit Care Nurs Clin North Am 2015; 28:9-19. [PMID: 26873756 DOI: 10.1016/j.cnc.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood pressure (BP) management is essential in neurocritical care settings to ensure adequate cerebral perfusion and prevent secondary brain injury. Despite consensus on the importance of BP monitoring, significant practice variations persist regarding optimal methods for monitoring and treatment of BP values among patients with neurologic injuries. This article provides a summary of research investigating various approaches for BP management in neurocritical care. Evidence-based recommendations, areas for future research, and current technological advancements for BP management are discussed.
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Affiliation(s)
- Molly McNett
- Nursing Research, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
| | - Jay Koren
- Surgical Intensive Care Unit, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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Zonneveld TP, Algra A, Dippel DWJ, Kappelle LJ, van Oostenbrugge RJ, Roos YBWEM, Wermer MJ, van der Worp HB, Nederkoorn PJ, Kruyt ND. The ThRombolysis in UnconTrolled Hypertension (TRUTH) protocol: an observational study on treatment strategy of elevated blood pressure in stroke patients eligible for IVT. BMC Neurol 2015; 15:241. [PMID: 26596237 PMCID: PMC4657238 DOI: 10.1186/s12883-015-0493-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with (recombinant) tissue plasminogen activator is an effective treatment in acute ischemic stroke. However, IVT is contraindicated when blood pressure is above 185/110 mmHg, because of an increased risk on symptomatic intracranial hemorrhage. In current Dutch clinical practice, two distinct strategies are used in this situation. The active strategy comprises lowering blood pressure with antihypertensive agents below these thresholds to allow start of IVT. In the conservative strategy, IVT is administered only when blood pressure drops spontaneously below protocolled thresholds. A retrospective analysis in two recent stroke trials showed a non-significant signal towards better functional outcome in the active group; robust evidence for either strategy, however, is lacking. We hypothesize that (I) the active strategy leads to a better functional outcome three months after acute ischemic stroke. Secondary hypotheses are that this effect occurs despite (II) increasing the number of symptomatic intracranial hemorrhages, and could be attributable to (III) a higher rate of IVT treatments and (IV) a shorter door-to-needle time. METHODS AND DESIGN The TRUTH is a prospective, observational, cluster-based, parallel group follow-up study; in which participating centers continue their current local treatment guidelines. Outcomes of patients admitted to centers with an active will be compared to those admitted to centers with a conservative strategy. The primary outcome is functional outcome on the modified Rankin Scale at three months. Secondary outcomes are symptomatic intracranial hemorrhage, IVT treatment and door-to-needle time. We based our sample size estimate on an ordinal analysis of the mRS with the "proportional odds" model. With the aforementioned signal observed in a recent retrospective study in these patients as an estimate of the effect size and with alpha 0 · 05, this analysis would have an 80 % power with a total number of 600 patients. Corrections for expected imbalance in group size and clustering effects resulted in a sample size of 1235 patients. DISCUSSION The TRUTH is the first large prospective study specifically studying IVT-candidates with elevated blood pressure, and has the potential to change clinical practice and optimize acute stroke care in these patients.
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Affiliation(s)
- T P Zonneveld
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.
| | - A Algra
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands. .,The Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - D W J Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - L J Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | | | - Y B W E M Roos
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.
| | - M J Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
| | - H B van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - P J Nederkoorn
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.
| | - N D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.
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13
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Acute Treatment of Blood Pressure After Ischemic Stroke and Intracerebral Hemorrhage. Neurol Clin 2015; 33:361-80. [DOI: 10.1016/j.ncl.2014.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bowry R, Navalkele DD, Gonzales NR. Blood pressure management in stroke: Five new things. Neurol Clin Pract 2014; 4:419-426. [PMID: 25317377 DOI: 10.1212/cpj.0000000000000085] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hypertension is a major modifiable risk factor for stroke, with an estimated 51% of stroke deaths being attributable to high systolic blood pressure globally.1,2 The management of hypertension in stroke is determined by timing, the type of stroke, use of thrombolysis, concurrent medical conditions, and pharmacologic variables. We highlight the details of elevated blood pressure management in the hyperacute/acute, subacute, and chronic stages of ischemic stroke and intracerebral hemorrhage.
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Affiliation(s)
- Ritvij Bowry
- University of Texas Health Sciences Center at Houston
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Matz K, Brainin M. Use of intravenous recombinant tissue plasminogen activator in patients outside the defined criteria: safety and feasibility issues. Expert Rev Neurother 2014; 13:177-85. [DOI: 10.1586/ern.12.166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Balami JS, Hadley G, Sutherland BA, Karbalai H, Buchan AM. The exact science of stroke thrombolysis and the quiet art of patient selection. ACTA ACUST UNITED AC 2013; 136:3528-53. [PMID: 24038074 DOI: 10.1093/brain/awt201] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The science of metric-based patient stratification for intravenous thrombolysis, revolutionized by the landmark National Institute of Neurological Disorders and Stroke trial, has transformed acute ischaemic stroke therapy. Recanalization of an occluded artery produces tissue reperfusion that unequivocally improves outcome and function in patients with acute ischaemic stroke. Recanalization can be achieved mainly through intravenous thrombolysis, but other methods such as intra-arterial thrombolysis or mechanical thrombectomy can also be employed. Strict guidelines preclude many patients from being treated by intravenous thrombolysis due to the associated risks. The quiet art of informed patient selection by careful assessment of patient baseline factors and brain imaging could increase the number of eligible patients receiving intravenous thrombolysis. Outside of the existing eligibility criteria, patients may fall into therapeutic 'grey areas' and should be evaluated on a case by case basis. Important factors to consider include time of onset, age, and baseline blood glucose, blood pressure, stroke severity (as measured by National Institutes of Health Stroke Scale) and computer tomography changes (as measured by Alberta Stroke Programme Early Computed Tomography Score). Patients with traditional contraindications such as wake-up stroke, malignancy or dementia may have the potential to receive benefit from intravenous thrombolysis if they have favourable predictors of outcome from both clinical and imaging criteria. A proportion of patients experience complications or do not respond to intravenous thrombolysis. In these patients, other endovascular therapies or a combination of both may be used to provide benefit. Although an evidence-based approach to intravenous thrombolysis for acute ischaemic stroke is pivotal, it is imperative to examine those who might benefit outside of protocol-driven practice.
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Affiliation(s)
- Joyce S Balami
- 1 Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
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Lyerly MJ, Albright KC, Boehme AK, Shahripour RB, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. The Potential Impact of Maintaining a 3-Hour IV Thrombolysis Window: How Many More Patients can we Safely Treat? JOURNAL OF NEUROLOGICAL DISORDERS & STROKE 2013; 1:1015. [PMID: 24471140 PMCID: PMC3901990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In 2008, the European Cooperative Acute Stroke Study-3 (ECASS-3) demonstrated that intravenous-tissue plasminogen activator could be safely administered for acute stroke patients presenting between 3 and 4.5 hours from symptom onset. Recently, the Food and Drug Administration rejected expansion of this time window in the United States. We sought to determine how many fewer patients would be treated by maintaining this restricted time window. METHODS We reviewed charts from patients who received intravenous thrombolysis at the University of Alabama at Birmingham between January 2009 and December 2011. Patients were divided into two groups (treated within 3 hours of onset, treated between 3 and 4.5 hours from onset). Demographics, stroke severity and protocol deviations according to the ECASS-3 trial were collected. Our safety measures were any hemorrhagic transformation, symptomatic intracerebral hemorrhage and systemic hemorrhage. RESULTS Two hundred and twelve patients were identified, of whom 192 were included in our analysis. A total of 36 patients (19%) were treated between 3 and 4.5 hours. No statistical differences were seen between age (p=0.633), gender (p=0.677), race (p=0.207) or admission stroke severity (p=0.737). Protocol deviations from the ECASS-3 criteria were found in 20 patients (56%). These were primarily age > 80 and aggressive blood pressure management. Despite these deviations, we did not see significant increases in the rates of adverse events in patients treated in the extended time window. CONCLUSIONS Our data are consistent with previously reported international data that IV thrombolysis can safely be used up to 4.5 hours from symptom onset. Restricting the time window to 3 hours would have resulted in almost one-fifth fewer patients treated at our center.
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Affiliation(s)
- Michael J. Lyerly
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
- Stroke Center, Birmingham Veterans Affairs Medical Center, USA
| | - Karen C. Albright
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, USA
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, USA
- Center for Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC), University of Alabama at Birmingham, USA
| | - Amelia K. Boehme
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, USA
| | | | - James T. Houston
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
| | - Pawan V. Rawal
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
| | - Niren Kapoor
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
| | - Muhammad Alvi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
| | - April Sisson
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
| | - Anne W. Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
- School of Nursing, University of Alabama at Birmingham, USA
| | - Andrei V. Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, USA
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Lyerly MJ, Albright KC, Boehme AK, Bavarsad Shahripour R, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. Safety of protocol violations in acute stroke tPA administration. J Stroke Cerebrovasc Dis 2013; 23:855-60. [PMID: 23954609 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/06/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator remains the only approved therapy for acute ischemic stroke (AIS) in the United States; however, less than 10% of patients receive treatment. This is partially because of the large number of contraindications, narrow treatment window, and physician reluctance to deviate from these criteria. METHODS We retrospectively analyzed consecutive patients who received IV thrombolysis at our stroke center for National Institute of Neurological Disorders and Stroke (NINDS) protocol violations and rates of symptomatic intracerebral hemorrhage (sICH). Other outcome variables included systemic hemorrhage, modified Rankin Scale at discharge, and discharge disposition. RESULTS A total of 212 patients were identified in our stroke registry between 2009 and 2011 and included in the analysis. Protocol violations occurred in 76 patients (36%). The most common violations were thrombolysis beyond 3 hours (26%), aggressive blood pressure management (15%), elevated prothrombin time (PT) or partial thromboplastin time (PTT) (6.6%), minor or resolving deficits (4.2%), unclear time of onset (3.9%), and stroke within 3 months (3%). There were no significant differences in any of the safety outcomes or discharge disposition between patients with or without protocol violations. Controlling for age, National Institutes of Health Stroke Scale on admission, and glucose on admission, there was no significant increase in sICH (odds ratio: 3.8; 95% confidence interval: .37-38.72) in the patients who had protocol violations. CONCLUSIONS Despite more than one third of patients receiving thrombolysis with protocol violations, overall rates of hemorrhage remained low and did not differ from those who did not have violations. Our data support the need to expand access to thrombolysis in AIS patients.
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Affiliation(s)
- Michael J Lyerly
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
| | - Karen C Albright
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, Birmingham, Alabama; Center for Excellence in Comparative Effectiveness Research for Eliminating Disparities, Minority Health and Health Disparities Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amelia K Boehme
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Reza Bavarsad Shahripour
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - James T Houston
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pawan V Rawal
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Niren Kapoor
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Muhammad Alvi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - April Sisson
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anne W Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrei V Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Fugate JE, Rabinstein AA. Contraindications to intravenous rtPA for acute stroke: A critical reappraisal. Neurol Clin Pract 2013; 3:177-185. [PMID: 29473642 DOI: 10.1212/cpj.0b013e318296f0a9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Only 1%-5% of patients with acute ischemic stroke presenting within 3 hours of symptoms receive IV recombinant tissue plasminogen activator (rtPA)-the only effective treatment available. The administration of rtPA is limited by extensive exclusion criteria, many of which are not based on evidence, but rather derived from expert opinion for large stroke trials. Over the past 15 years, experiences with the use of rtPA in clinical practice have led to evidence suggesting that several of the current contraindications for rtPA are unnecessary and overly restrictive. In this review, we analyze the evidence-most of which is derived from observational research-supporting or contradicting current contraindications for administering IV rtPA to acute ischemic stroke patients.
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Cogez J, Bonnet AL, Touzé E. Pression artérielle: quel objectif à l’occasion d’un accident vasculaire cérébral aigu ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0649-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hesselfeldt R, Gyllenborg J, Steinmetz J, Do HQ, Hejselbæk J, Rasmussen LS. Is air transport of stroke patients faster than ground transport? A prospective controlled observational study. Emerg Med J 2013; 31:268-72. [PMID: 23389831 DOI: 10.1136/emermed-2012-202270] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Helicopters are widely used for interhospital transfers of stroke patients, but the benefit is sparsely documented. We hypothesised that helicopter transport would reduce system delay to thrombolytic treatment at the regional stroke centre. METHODS In this prospective controlled observational study, we included patients referred to a stroke centre if their ground transport time exceeded 30 min, or they were transported by a secondarily dispatched, physician-staffed helicopter. The primary endpoint was time from telephone contact to triaging neurologist to arrival in the stroke centre. Secondary endpoints included modified Rankin Scale at 3 months, 30-day and 1-year mortality. RESULTS A total of 330 patients were included; 265 with ground transport and 65 with helicopter, of which 87 (33%) and 22 (34%), received thrombolysis, respectively (p=0.88). Time from contact to triaging neurologist to arrival in the regional stroke centre was significantly shorter in the ground group (55 (34-85) vs 68 (40-85) min, p<0.01). The distance from scene to stroke centre was shorter in the ground group (67 (42-136) km) than in the helicopter group (83 (46-143) km) (p<0.01). We did not detect significant differences in modified Rankin Scale at 3 months, in 30-day (9.4% vs 0%; p=0.20) nor 1-year (18.8% vs 13.6%; p=0.76) mortality between ground and helicopter transport. CONCLUSIONS We found significantly shorter time from contact to triaging neurologist to arrival in the regional stroke centre if stroke patients were transported by primarily dispatched ground ambulance compared with a secondarily dispatched helicopter.
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Affiliation(s)
- Rasmus Hesselfeldt
- Department of Anaesthesia, Copenhagen University Hospital, , Rigshospitalet, Copenhagen, Denmark
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22
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Skolarus LE, Scott PA, Burke JF, Adelman EE, Frederiksen SM, Kade AM, Kalbfleisch JD, Ford AL, Meurer WJ. Antihypertensive treatment prolongs tissue plasminogen activator door-to-treatment time: secondary analysis of the INSTINCT trial. Stroke 2012; 43:3392-4. [PMID: 23033348 DOI: 10.1161/strokeaha.112.662684] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Identifying modifiable tissue plasminogen activator treatment delays may improve stroke outcomes. We hypothesized that prethrombolytic antihypertensive treatment (AHT) may prolong door-to-treatment time (DTT). METHODS We performed an analysis of consecutive tissue plasminogen activator-treated patients at 24 randomly selected community hospitals in the Increasing Stroke Treatment through Interventional Behavior Change Tactics (INSTINCT) trial between 2007 and 2010. DTT among stroke patients who received prethrombolytic AHT were compared with those who did not receive prethrombolytic AHT. We then calculated a propensity score for the probability of receiving prethrombolytic AHT using logistic regression with demographics, stroke risk factors, home medications, stroke severity (National Institutes of Health Stroke Scale), onset-to-door time, admission glucose, pretreatment blood pressure, emergency medical service transport, and location at time of stroke as independent variables. A paired t test was performed to compare the DTT between the propensity-matched groups. RESULTS Of 534 tissue plasminogen activator-treated stroke patients analyzed, 95 received prethrombolytic AHT. In the unmatched cohort, patients who received prethrombolytic AHT had a longer DTT (mean increase, 9 minutes; 95% confidence interval, 2-16 minutes) than patients who did not. After propensity matching, patients who received prethrombolytic AHT had a longer DTT (mean increase, 10.4 minutes; 95% confidence interval, 1.9-18.8) than patients who did not receive prethrombolytic AHT. CONCLUSIONS Prethrombolytic AHT is associated with modest delays in DTT. This represents a potential target for quality-improvement initiatives. Further research evaluating optimum prethrombolytic hypertension management is warranted.
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Affiliation(s)
- Lesli E Skolarus
- Department of Biostatics, University of Michigan, School of Public Health, 1500 East Medical Center, Ann Arbor, MI 48109-5855, USA.
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Kimura K, Sakamoto Y, Iguchi Y, Shibazaki K, Watanabe M, Aoki J, Inoue T, Uemura J. A simple clinical and MRI scale to predict good outcome in t-PA patients. Neurol Res 2011; 33:1038-43. [PMID: 22196756 DOI: 10.1179/1743132811y.0000000031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND PURPOSE The frequency of good outcome at 3 months after tissue plasminogen activator (t-PA) therapy is ∼35%. The present study aimed to devise a simple scale to predict good outcome using clinical factors and magnetic resonance imaging (MRI) findings before and immediately after t-PA infusion. METHODS Consecutive patients with acute ischemic stroke treated with t-PA within 3 hours of stroke onset were studied prospectively. We assessed clinical factors independently associated with good outcome [modified Rankin scale (mRS): 0-1] at 3 months after t-PA therapy. We created a simple scale to predict good outcome in t-PA patients using factors selected by multivariate logistic regression analysis. RESULTS Subjects comprised 105 patients (69 men; median age, 74 years). Multivariate logistic regression analysis revealed the following independent factors associated with good outcome: baseline National Institutes of Health Stroke Scale (NIHSS) <11 [odds ratio (OR), 13·64; 95% confidence interval (CI), 3·588-51·822; P = 0·0001], glucose <150 mg/dl (OR, 3·76; 95%CI, 1·014-13·963; P = 0·0475), and early recanalization within 1 hour after t-PA infusion (OR, 5·28; 95%CI, 1·179-23·656; P = 0·0296). Those three variables were selected for use in the good outcome scale, with NIHSS <11 as 2 points, glucose <150 mg/dl as 1 point, and early recanalization as 1 point. Frequencies of patients with good outcome for each score were as follows: score 0, 0·0%; score 1, 7·1%; score 2, 43·5%; score 3, 65·4%; and score 4, 71·4%. The C statistic for the score was 0·849 (95%CI, 0·776-0·922). CONCLUSION A simple clinical and MRI scale can predict good outcome in t-PA patients.
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Affiliation(s)
- Kazumi Kimura
- Kawasaki Medical School, Kurashiki City, Okayama, Japan.
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Peacock WF, Hilleman DE, Levy PD, Rhoney DH, Varon J. A systematic review of nicardipine vs labetalol for the management of hypertensive crises. Am J Emerg Med 2011; 30:981-93. [PMID: 21908132 DOI: 10.1016/j.ajem.2011.06.040] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 05/27/2011] [Accepted: 06/30/2011] [Indexed: 11/16/2022] Open
Abstract
Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. This systematic review presents a synthesis of published studies that compare the antihypertensive agents nicardipine and labetalol in patients experiencing acute hypertensive crises. A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.
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Affiliation(s)
- W Frank Peacock
- Department of Emergency Medicine E19, The Cleveland Clinic, Cleveland, OH 44195, USA.
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Ossi RG, Meschia JF, Barrett KM. Hospital-based management of acute ischemic stroke following intravenous thrombolysis. Expert Rev Cardiovasc Ther 2011; 9:463-72. [PMID: 21517730 DOI: 10.1586/erc.11.42] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Timely administration of proven therapies remains the primary goal in acute stroke care. Following reperfusion therapy with intravenous thrombolysis, medical and neurological complications may develop in the hospitalized patient with acute ischemic stroke. Medical complications may include deep venous thrombosis, pulmonary embolism, aspiration, systemic infections and neuropsychiatric disturbances. Neurologic complications may include symptomatic intracranial hemorrhage, cerebral edema with elevated intracranial pressure, and post-stroke seizures. Early initiation of preventative strategies and proper management of common complications may improve both short-term and long-term outcomes. Here we review evidence-based management strategies for hospitalized acute ischemic stroke patients following intravenous thrombolysis.
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Affiliation(s)
- Raid G Ossi
- Cerebrovascular Division, Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Fischer U, Rothwell PM. Blood pressure management in acute stroke: does the Scandinavian Candesartan Acute Stroke Trial (SCAST) resolve all of the unanswered questions? Stroke 2011; 42:2995-8. [PMID: 21852619 DOI: 10.1161/strokeaha.111.619346] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Urs Fischer
- Department of Neurology, University Hospital Bern and University of Bern, Inselspital, Freiburgstrasse 4, 3010 Bern, Switzerland.
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Shulkin DJ, Jewell KE, Alexandrov AW, Bernard DB, Brophy GM, Hess DC, Kohlbrenner J, Martin-Schild S, Mayer SA, Peacock WF, Qureshi AI, Sung GY, Lyles A. Impact of systems of care and blood pressure management on stroke outcomes. Popul Health Manag 2011; 14:267-75. [PMID: 21506730 DOI: 10.1089/pop.2010.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.
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Tsivgoulis G, Kotsis V, Giannopoulos S. Intravenous Thrombolysis for Acute Ischaemic Stroke: Effective Blood Pressure Control Matters. Int J Stroke 2011; 6:125-7. [DOI: 10.1111/j.1747-4949.2010.00570.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In this Leading opinion we summarise the observational evidence endorsing current guidelines that advocate effective blood pressure control before and during an rtPA infusion and indicate that a more active blood pressure-lowering approach immediately after intravenous thrombolysis appears to be a promising therapeutic option that should be formerly evaluated in a randomised clinical trial setting. Acute ischaemic stroke is a highly treatable neuroemergency and the efficacy of the available treatment is not only related to the speed by which it is administered but also by the effective control of modifiable adverse outcome predictors including elevated blood pressure levels.
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Affiliation(s)
- Georgios Tsivgoulis
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Vasilios Kotsis
- Third Department of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
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Kimura K, Sakamoto Y, Iguchi Y, Shibazaki K. Clinical and MRI Scale to Predict Very Poor Outcome in Tissue Plasminogen Activator Patients. Eur Neurol 2011; 65:291-5. [DOI: 10.1159/000327690] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 03/22/2011] [Indexed: 11/19/2022]
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Dharmasaroja PA, Dharmasaroja P, Muengtaweepongsa S. Outcomes of Thai patients with acute ischemic stroke after intravenous thrombolysis. J Neurol Sci 2011; 300:74-7. [DOI: 10.1016/j.jns.2010.09.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 09/23/2010] [Accepted: 09/23/2010] [Indexed: 11/25/2022]
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Hocker S, Morales-Vidal S, Schneck MJ. Management of Arterial Blood Pressure in Acute Ischemic and Hemorrhagic Stroke. Neurol Clin 2010; 28:863-86. [DOI: 10.1016/j.ncl.2010.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Hypertension is the most prevalent of the modifiable risk factors for stroke. The benefits of blood pressure (BP) lowering on primary and secondary prevention of stroke are undeniable. Despite this, BP control in hypertensive individuals and patients with prior cerebrovascular events is suboptimal. Noncompliance, inappropriate antihypertensive usage and under-utilization of medications contribute significantly to inadequate BP control. Recently, elegantly designed studies that assessed the preventive role of BP lowering in patients with cerebrovascular disease have helped clarify management issues in terms of BP targets and effective antihypertensive regimens. Current evidence suggests that BP targets for primary and secondary prevention are suboptimal and need reassessment. The effect of BP modulation in acute stroke is still not completely understood. Although the thresholds for BP treatment in acute stroke have been recommended, BP targets are as yet ill-defined. The available evidence supports early lowering of blood pressure following stroke. This review discusses the impact of blood pressure on stroke incidence and outcomes, outlines the recommendations for blood pressure lowering in stroke and delineates questions that still need to be addressed.
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Affiliation(s)
- Monica Saini
- Division of Neurology, Department of Medicine, University of Alberta, AB, Canada.
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Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Curr Opin Neurol 2010; 23:46-52. [PMID: 20038827 DOI: 10.1097/wco.0b013e3283355694] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Elevated blood pressure (BP) is frequent in patients with acute ischemic stroke. Pathophysiological data support its usefulness to maintain adequate perfusion of the ischemic penumba. This review article aims to summarize the available evidence from clinical studies that examined the prognostic role of BP during the acute phase of ischemic stroke and intervention studies that assessed the efficacy of active BP alteration. RECENT FINDINGS We found 34 observational studies (33,470 patients), with results being inconsistent among the studies; most studies reported a negative association between increased levels of BP and clinical outcome, whereas a few studies showed clinical improvement with higher BP levels, clinical deterioration with decreased BP, or no association at all. Similarly, the conclusions drawn by the 18 intervention studies included in this review (1637 patients) were also heterogeneous. Very recent clinical data suggest a possible beneficial effect of early treatment with some antihypertensives on late clinical outcome. SUMMARY Observational and interventional studies of management of acute poststroke hypertension yield conflicting results. We discuss different explanations that may account for this and discuss the current guidelines and pathophysiological considerations for the management of acute poststroke hypertension.
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Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Curr Opin Neurol 2010. [DOI: 10.1097/wco.0b013e328334e9d9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Toyoda K, Koga M, Naganuma M, Shiokawa Y, Nakagawara J, Furui E, Kimura K, Yamagami H, Okada Y, Hasegawa Y, Kario K, Okuda S, Nishiyama K, Minematsu K. Routine Use of Intravenous Low-Dose Recombinant Tissue Plasminogen Activator in Japanese Patients. Stroke 2009; 40:3591-5. [DOI: 10.1161/strokeaha.109.562991] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A retrospective, multicenter, observational study was conducted to document clinical outcomes and to identify outcome predictors in patients treated with low-dose intravenous recombinant tissue plasminogen activator (0.6 mg/kg alteplase), which was approved in Japan in 2005, within 3 hours of stroke onset.
Methods—
Consecutive patients with stroke treated with recombinant tissue plasminogen activator in 10 Japanese stroke centers were included.
Results—
A total of 600 patients (377 men, 72±12 years old) were studied. Median National Institutes of Health Stroke Scale scores decreased from 13 before recombinant tissue plasminogen activator to 8 at 24 hours later. Symptomatic intracerebral hemorrhage within 36 hours with a ≥1-point increase from the baseline National Institutes of Health Stroke Scale score developed in 23 patients (3.8%; 95% CI, 2.6% to 5.7%). At 3 months, 43 patients had died (7.2%; 5.4% to 9.5%), and 199 patients (33.2%; 29.5% to 37.0%) had a modified Rankin Scale score ≤1. Analysis of 399 patients with a premorbid modified Rankin Scale score ≤1 who met the criteria of the European license (≤80 years old, an initial National Institutes of Health Stroke Scale score ≤24, etc) showed that 40.6% (35.9% to 45.5%) had a 3-month modified Rankin Scale score ≤1. After multivariate adjustment, younger age, lower initial National Institutes of Health Stroke Scale score, absence of internal carotid artery occlusion, higher Alberta Stroke Program Early CT Score on CT, and absence of intravenous antihypertensives just before recombinant tissue plasminogen activator were independently related to a 3-month modified Rankin Scale score ≤1. Congestive heart failure and hyperglycemia were independently related to mortality.
Conclusions—
Three-month outcomes of patients receiving low-dose intravenous recombinant tissue plasminogen activator therapy in the present study were similar to those from postmarketing surveys using 0.9 mg/kg alteplase.
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Affiliation(s)
- Kazunori Toyoda
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Masatoshi Koga
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Masaki Naganuma
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Yoshiaki Shiokawa
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Jyoji Nakagawara
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Eisuke Furui
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Kazumi Kimura
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Hiroshi Yamagami
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Yasushi Okada
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Yasuhiro Hasegawa
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Kazuomi Kario
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Satoshi Okuda
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Kazutoshi Nishiyama
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
| | - Kazuo Minematsu
- From the Cerebrovascular Division (K.T., M.K., M.N., K.M.), Department of Medicine, National Cardiovascular Center, Suita, Japan; Departments of Neurosurgery (Y.S.), Neurology (K.N.), and Stroke Center (Y.S., K.N.), Kyorin University School of Medicine, Mitaka, Japan; the Department of Neurosurgery and Stroke Center (J.N.), Nakamura Memorial Hospital, Sapporo, Japan; the Department of Stroke Neurology (E.F.), Kohnan Hospital, Sendai, Japan; the Department of Stroke Medicine (K. Kimura), Kawasaki
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Winters ME, Mitarai T, Brady WJ. The critical care literature 2008. Am J Emerg Med 2009. [DOI: 10.1016/j.ajem.2009.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Casiglia E, Tikhonoff V, Pessina AC. Hypertension in the elderly and the very old. Expert Rev Cardiovasc Ther 2009; 7:659-65. [PMID: 19505281 DOI: 10.1586/erc.09.17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
High systolic blood pressure represents a challenge for the modern world. Epidemiologists are in the best position to appreciate the importance of systolic hypertension and its cardiovascular consequences. Although the label of hypertension seems to have lower importance in the elderly, and above all in the very old, than in younger people, high systolic and high pulse pressure are risk factors for cardiovascular events and necessitates treatment. Unfortunately, due to indolence and lack of aggressiveness, only a limited fraction of elderly hypertensive patients receives adequate therapy.
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Affiliation(s)
- Edoardo Casiglia
- Department of Clinical & Experimental Medicine, University of Padova, Via Giustiniani No. 2, Padova I-35128, Italy.
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