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Terrett LA, McIntyre L, O'Kelly C, Ramsay T, Turgeon AF, English SW. Blood Pressure Management in Early Aneurysmal Subarachnoid Hemorrhage: A National Cross-Sectional Survey of Canadian Intensivists and Cerebrovascular Neurosurgeons. Neurocrit Care 2024:10.1007/s12028-024-02011-4. [PMID: 38862709 DOI: 10.1007/s12028-024-02011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND In aneurysmal subarachnoid hemorrhage (aSAH), rebleeding of the culprit aneurysm is associated with significant morbidity and mortality. Blood pressure reduction to specific target levels, with the goal of preventing rebleeding, has been a mainstay of care prior to definitively securing the aneurysm. Clinical practice guidelines have recently changed and no longer recommend specific blood pressure targets. This survey aims to identify the reported practice patterns and beliefs regarding blood pressure management during the early phase of aSAH. METHODS We conducted a self-administered, Web-based survey of critical care physicians and cerebrovascular neurosurgeons practicing in Canada. The questionnaire contained 21 items, including 3 case-based scenarios to elicit blood pressure target selection, both before and after aneurysm securing. RESULTS In the presecured period, systolic blood pressures of 160 mm Hg (50% [144 of 287]) and 140 mm Hg (42% [120 of 287]) were the most frequently selected upper-limit targets. In the postsecured period, a systolic blood pressure of 180 mm Hg (32% [93 of 287]) was the most frequently selected upper-limit target, but there was a wide distribution of targets selected across all three cases ranging from 100 to > 200 mm Hg. A mean arterial pressure of 65 mm Hg was the most common lower-limit target in both the presecured and postsecured periods. There was little change in blood pressure targets with increasing clinical severity. Predictors of higher or lower blood pressure target selection and barriers to implementation of the desired target were identified. CONCLUSIONS During the presecured period, nearly half of the reported upper-limit blood pressure targets are lower than previous guideline recommendations. These targets remain consistent despite increasing clinical severity and could potentially exacerbate cerebral ischemia and negatively impact clinical outcomes. In the postsecured period, there is wide variation in the reported blood pressure targets. A clinical trial is urgently needed to guide decision-making.
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Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
- Department of Adult Critical Care, Saskatchewan Health Authority, 103 Hospital Drive, Saskatoon, SK, S7N0W8, Canada.
| | - Lauralyn McIntyre
- Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Cian O'Kelly
- Division of Neurosurgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Tim Ramsay
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre Hospitalier Universitaire de Québec - Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
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Mutoh T, Aono H, Seto W, Kimoto T, Tochinai R, Moroi J, Ishikawa T. Factors Influencing Discontinuation of Clazosentan Therapy in Elderly Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study from a Japanese Single Center. Med Sci Monit 2024; 30:e943303. [PMID: 38361355 PMCID: PMC10877966 DOI: 10.12659/msm.943303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/28/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Clazosentan is an endothelin receptor antagonist approved in Japan for preventing cerebral vasospasm and vasospasm-associated cerebral ischemia and infarction. This study included elderly patients aged ≥75 years with aneurysmal subarachnoid hemorrhage (SAH) and aimed to evaluate the factors associated with discontinuing anti-vasospasm therapy with clazosentan. MATERIAL AND METHODS In this single-center retrospective observational study, we extracted diagnostic and therapeutic work-up data of consecutive 40 patients with SAH treated with clazosentan infusion (10 mg/h) as first-line anti-vasospasm therapy between May 2022 and August 2023. Patient data were compared between the discontinued and completed groups, and related factors for the discontinuation were further analyzed. RESULTS Clazosentan was discontinued in 22% (n=9) of patients due to intolerable dyspnea accompanied by hypoxemia at 5±3 days after therapy initiation, in which 44% (n=4) were elderly (≥75 years). Patients who discontinued clazosentan therapy showed significantly lower urine volumes compared with those who completed the therapy (P<0.05). Multivariate regression analysis revealed that day-to-day urine volume variance and older age were independent risk factors for drug cessation (P<0.05). The cut-off value for predicting clazosentan discontinuation was -0.7 mL/kg/h with sensitivity of 86% and specificity of 75% (area under the curve: 0.76±0.10; 95% confidence interval: 0.56-0.96; P=0.035). CONCLUSIONS Our results suggest that approximately 20% of SAH patients suffered from intolerable respiratory symptoms attributable to hypoxemia. We found that both reduced day-to-day urine volume variation and older age are independent risk factors for drug discontinuation.
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Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Hiroaki Aono
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Wataru Seto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Takehiro Kimoto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Ryota Tochinai
- Department of Veterinary Pathophysiology and Animal Health, Graduate School of Agriculture and Life Sciences, the University of Tokyo, Tokyo, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita, Japan
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Mutoh T, Aono H, Seto W, Kimoto T, Tochinai R, Moroi J, Ishikawa T. Cardiopulmonary Events of the Elderly (≥75 Years) during Clazosentan Therapy after Subarachnoid Hemorrhage: A Retrospective Study from a Tertiary Stroke Center in Japan. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:185. [PMID: 38276064 PMCID: PMC10819954 DOI: 10.3390/medicina60010185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
Clazosentan has been shown to prevent vasospasm and reduce mortality in patients after aneurysmal subarachnoid hemorrhage (SAH) and has been approved for clinical use in Japan; however, its systemic events in the elderly (aged ≥ 75 years) have not been well-documented. Here, we report serious/intolerable cardiopulmonary complications requiring discontinuation of drug therapy in elderly SAH patients. In this single-center case series study, medical records of consecutive SAH patients treated postoperatively with clazosentan (10 mg/h) between June 2022 and May 2023 were reviewed retrospectively. Thirty-three patients received clazosentan therapy, of whom six were elderly with a mean age of 80.3 ± 5.2 (range 75-89) years. Among them, despite no obvious medical history of systemic abnormalities, clazosentan was discontinued in three (50%) patients due to pleural effusion and hypoxemia with or without hypotension at 5 ± 3 days after therapy initiation, which was higher than the incidence for younger patients (15%). The elderly patients had significantly lower urine output (1935 ± 265 vs. 1123 ± 371 mL/day, p = 0.03) and greater weight gain (2.1 ± 1.1 vs. 4.2 ± 1.9 kg from baseline, p = 0.04) than patients who completed the therapy. One 89-year-old female developed congestive heart failure and hydrostatic pulmonary edema associated with increased intravascular and lung volumes even after therapy was discontinued, while the remaining two cases recovered within 2 days after drug cessation. These results suggest that elderly patients are more vulnerable to fluid retention and have a higher risk of cardiopulmonary complications during clazosentan therapy than younger patients. Careful monitoring of urine volume and weight gain and caution regarding age- and therapy-related hemodynamic insufficiencies are required.
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Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
- Department of Aging Research and Geriatric Medicine, Institute of Development, Aging and Cancer, Tohoku University, Sendai 980-8575, Japan
| | - Hiroaki Aono
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
| | - Wataru Seto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
| | - Takehiro Kimoto
- Department of Pharmaceutics, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
| | - Ryota Tochinai
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
- Department of Aging Research and Geriatric Medicine, Institute of Development, Aging and Cancer, Tohoku University, Sendai 980-8575, Japan
- Department of Veterinary Pathophysiology and Animal Health, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-8654, Japan
| | - Junta Moroi
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita Cerebrospinal and Cardiovascular Center, Akita 010-0874, Japan
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