Blood Pressure Goals in Acute Stroke-How Low Do You Go?

Blood Pressure Control in Acute Stroke: Labetalol or Nicardipine?

PURPOSE

To assess the safety and efficacy of continuous infusion (CIV)-labetalol compared to -nicardipine in controlling blood pressure (BP) in the acute stroke setting.

MATERIALS

Patients were eligible if they had a diagnosis of an acute stroke and were administered either CIV-labetalol or CIV-nicardipine. Study outcomes were assessed within the first 24 h of the antihypertensive infusion.

RESULTS

A total of 3,093 patients were included with 3,008 patients in the CIV-nicardipine group and 85 in the CIV-labetalol group. No significant difference was observed in percent time at goal BP between the nicardipine (82%) and labetalol (85%) groups (p = 0.351). There was also no difference in BP variability between nicardipine (37%) and labetalol (39%) groups (p = 0.433). Labetalol was found to have a shorter time to goal BP as compared to nicardipine (24 min vs. 40 min; p = 0.021). While CIV-nicardipine did have a higher incidence of tachycardia compared to labetalol (17% vs. 4%; p <0.001), the incidence of hypotension (13% vs. 15%; p = 0.620) and bradycardia (24% vs. 22%; p = 0.797) were similar.

CONCLUSIONS

These results indicate that CIV-labetalol and CIV-nicardipine are comparable in safety and efficacy in controlling BP for patients with acute stroke.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review

Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.

[Prevalence and characteristics of metabolic syndrome in adults admitted to a health care center for ischemic stroke]

Introduction

Background: Chile has experienced an increase in the prevalence of metabolic syndrome (MS) among the adult population. MS is proposed as a predictor for the occurrence of vascular defects causing ischemic stroke. Objective: to determine the frequency and characteristics of MS in a sample of adults after an ischemic ACV. Methods: a descriptive, cross-sectional study that consisted of reviewing variables related to MS in 180 adult patients admitted to a clinic for an ischemic stroke between the years 2011 and 2017. Weight and height measurements were considered to obtain BMI and nutritional status. Waist circumference (CC), systolic (PAS) and diastolic blood pressure (PAD), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides (TG), and glycemia were also measured. Results: 62.8 % of the sample had MS. BMI (CI, 28.5-29.9; p = 0.001), CC (CI, 101.3-105.3; p = 0.001), PAS (CI, 147.4-155.7; p = 0.000), PAD (CI, 87.7-93.6; p = 0.000), glycemia (CI, 132.9-159.2; p = 0.000), and TG (CI, 181.2-228.8; p = 0.000) were higher in the group with SM. HDL-cholesterol (CI, 35.5-39.2; p = 0.000) was lower in this same group. Older age (p = 0.007), male gender (p = 0.017), and excess nutritional status (p = 0.000) had a positive association with MS. Of the subjects with MS, there were no differences obtained when comparing the components that define MS between men and women. Conclusion: our findings reveal a high frequency of MS in adults admitted to a clinic for ischemic stroke.

The Relationship Between Admission Systolic Blood Pressure and Mortality in Telestroke Patients

Background: A "U-shaped" relationship between admission blood pressure (BP) and mortality (wherein patients within a middle range have better outcomes than patients at higher or lower extremes) in patients receiving intravenous recombinant tissue-plasminogen activator (tPA) has been previously described. We aim to determine if this U-shaped relationship persists for patients in a telestroke setting regardless of tPA administration. Materials and Methods: We conducted a retrospective chart review of the prospectively collected registry data for all patients seen through the Medical University of South Carolina (MUSC) telestroke network. Admission systolic BP (SBP) was divided into quartiles with thresholds based on the 25th, 50th, and 75th percentiles as cut points separately by tPA status. The primary outcomes of this study were odds of 90-day modified Rankin scale ≤2 and 90-day mortality. Logistic regression analyses were used to analyze associations between BP quartiles and these outcomes, adjusted for relevant clinical covariates. Results: Our sample comprised 1,232 patients evaluated for telestroke, 616 of whom received tPA. Patients in the second (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.77 in the tPA group, OR 0.27, 95% CI 01.0-0.78 in the non-tPA group) and third (OR 0.26, 95% CI 0.11-0.64 in the tPA group, OR 0.36, 95% CI 0.14-0.92 in the non-tPA group) quartiles of admission SBP had lower adjusted odds of 90-day mortality. Conclusions: Our findings support a U-shaped relationship between admission SBP and 90-day mortality in acute stroke patients regardless of tPA administration, after adjustment for relevant covariates. Further research into interventions regarding BP management poststroke is warranted.

Cutting Edge Acute Ischemic Stroke Management

Acute ischemic stroke (AIS) is a medical emergency that requires prompt recognition and streamlined work-up to ensure that time-dependent therapies are initiated to achieve the best outcomes. This article discusses frequently missed AIS in the emergency department, the role of various imagining modalities in the work-up of AIS, updates on the use of intravenous thrombolytics and endovascular therapy for AIS, pearls on supportive care management of AIS, and prehospital and hospital process improvements to shorten door-to-needle time.

Antihypertensive therapy in acute ischemic stroke: where do we stand?

Despite the proven benefits of strict blood pressure (BP) control on primary and secondary prevention of stroke, management of acute hypertensive response in the early post-stroke period is surrounded by substantial controversy. Observational studies showed that raised BP on ischemic stroke onset is prognostically associated with excess risk for early adverse events and mortality. By contrast, randomized controlled trials and recent meta-analyses showed that although antihypertensive therapy effectively controls elevated BP in the acute stage of ischemic stroke, this BP-lowering effect is not translated into improvement in the risk of death or dependency. On this basis, acute and aggressive BP responses within 24 h of stroke onset should be avoided and antihypertensive therapy is recommended only for patients presenting with acute ischemic stroke and BP > 220/120 mmHg or those with BP > 185/110 mmHg who are eligible for therapy with intravenous tissue plasminogen activator. By contrast, recent clinical trials showed that intensive BP lowering to levels < 140 mmHg for systolic BP is safe and lowers the risk of hematoma expansion in patients with acute intra-cerebral hemorrhage and this BP target is recommended by current international guidelines. Herein, we provide an overview of randomized trials and recent meta-analyses on the management of hypertension during the acute stage of ischemic stroke. We discuss several areas of uncertainty and conclude with perspectives for future research.