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Blood pressure in acute
stroke
Presented by Ri李俊豪
Guidelines for Medical Care and
Treatment of Blood Pressure in
Patients with Acute Stroke
Joseph P. Broderick, M.D. University of Cincinnati Medical Center
Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996
Overview
• over 80% have a BP >160/90 during initial post stroke phase
and fall spontaneously in the subsequent 10–14 days.
• Because cerebral autoregulation is impaired after the acute
event, cerebral blood flow is very sensitive to changes in
systemic BP levels.
• Ischemic: increasing blood flow to the ischaemic penumbra.
• : increasing the risk of cerebral oedema haemorrhagic
transformation of the infarct.
• ICH: lowering blood pressure is to decrease the risk of ongoing
bleeding from ruptured small arteries and arterioles.
• decrease CPP and theoretically worsen brain injury
The mechanisms underlying the
rise in BP post stroke
• impairment of baroreceptor sensitivity
• increased sympathetic nervous system
activity
• activation of the renin aldosterone
mechanisms
• the Cushing reflex
Intracranial hemorrhage
• Control of elevated blood pressure has never been shown to
decrease the risk of ongoing or recurrent bleeding in patients
with intracerebral hemorrhage.
• treatment of moderate and severe elevations of blood pressure
(systolic BP> 180 mm Hg or MAP> 130 mm Hg).
• The goal of treatment : MAP of 100-130 mm Hg or to the low
hypertensive range (e.g., systolic pressure of 140-160 mm Hg).
• If systolic arterial blood pressure falls below 90 mm Hg,
pressors should be given.
guidelines for antihypertensive
therapy in acute stroke
• 1. If systolic BP is >230 mm Hg or diastolic BP >140 mm Hg on 2
readings 5 minutes apart, institute nitroprusside.
• 2. If systolic BP is 180 to 230 mm Hg, diastolic BP 105 to 140 mm
Hg, or mean arterial BP 130 mm Hg on 2 readings 20 minutes
apart, institute intravenous labetalol, esmolol or enalapril,
• 3. If systolic BP is <180 mm Hg and diastolic BP <105 mm Hg,
defer antihypertensive therapy. Choice of medication depends
on other medical contraindications (eg, avoid labetalol in
patients with asthma).
• 4. If ICP monitoring is available, cerebral perfusion pressure
should be kept at >70 mm Hg.
The antihypertensive medication
• quick in onset and easily titratable.
• Intravenous labetalol is an excellent choice because it is fastacting, titratable, and has no known adverse effect on either ICP
or autoregulation of local cerebral flow. (Intravenous enalapril )
• For more severe elevations (e.g., diastolic pressures > 130 mm
Hg) nitroprusside is recommended. Theoretically, nitroprusside
can increase ICP because it is a cerebral arterial vasodilator.
( clinical use:-, easiest medication to titrate.)
• Calcium channel blockers, such as sublingual nifedipine, are
less predictable, slower in onset, and can dilate cerebral arteries.
( as a second-line medication when the other medications
cannot be used.)
Blood Pressure Management in ICH
Elevated blood pressure
• Labetalol5–100 mg/h by intermittent
bolus doses of 10–40 mg or continuous
drip (2–8 mg/min)
• Esmolol500 µg/kg as a load;
maintenance use, 50–200 µg/kg/min
• Nitroprusside0.5–10 µg /kg/min
• Hydralazine10–20 mg Q 4–6 h
• Enalapril0.625–1.2 mg Q 6 h as needed
Low blood pressure
• Volume replenishment is the first line of approach.
• Isotonic saline or colloids can be used and monitored with CVP
• If hypotension persists after correction of volume deficit,
continuous infusions of pressors should be considered,
particularly for low systolic blood pressure such as <90 mm Hg.
• Phenylephrine2–10 µg · kg-1 · min-1
• Dopamine2–20 µg · kg-1 · min-1
• NorepinephrineTitrate from 0.05–0.2 µg · kg-1 · min-1
Ischemic stroke
• Unless systolic BP> 220 mm Hg or diastolic BP> 120 mm Hg
(sustained on repeated measurement), elevated blood pressure
should not be treated within the first day after ischemic stroke.
• The ischemic penumbra loses autoregulation, and perfusion is
directly linked to mean arterial pressure.
• Acute elevations in blood pressure are often transient, and
spontaneous declines are common.
• Overzealous treatment of hypertension following acute
ischemic stroke can convert the ischemic penumbra into an
infarct.
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Brazilian researchers.Dr Jamary Oliveira-Filho
and Colleagues from the Hospital Sao Rafael
and the Federal University of Bahia in Salvador
studied blood pressure (BP) changes in 115 patients
who had recently suffered a stroke.
The average BP on admittance to hospital was
160/94mmHg.
All patients experienced a drop in BP in the acute
phase of disease (24 hours after the stroke)
spontaneously or with medication.
Forty-four of the patients had a poor outcome three
months later, requiring assistance to complete
everyday activities such as eating and dressing.
Each 10 % decrease in systolic BP during the first 24
hours after stroke nearly doubled the likelihood of
poor outcome three months later.
The two exceptions
• (1) after use of tissue plasminogen
activator (t-PA), blood pressure should
be maintained below 185/110 mm Hg
• (2) in the presence of myocardial
infarction, heart failure or aortic
dissection, elevated blood pressure
should be treated aggressively.
Algorithm for Ischemic Stroke
• If diastolic BP > 140 mm Hg occurs on 2 readings 5
minutes apart, then start a continuous IV infusion of
an antihypertensive agent such as sodium
nitroprusside
• If systolic BP is > 220 mm Hg or diastolic BP is 121-140
mm Hg or mean arterial blood pressure is > 130 mm
Hg on two readings 20 minutes apart, then give an easily
titratable antihypertensive medication such as
labetalol at 10 mg IV over 1-2 minutes.
• If systolic BP is 185-220 mm Hg or diastolic BP is 105120 mm Hg, emergency therapy should be deferred in
the absence of left ventricular failure, aortic dissection,
or acute myocardial ischemia.
• In acute stroke patients with systolic blood pressure
< 185 mm Hg or diastolic blood pressure < 105 mm
Hg, antihypertensive therapy is usually not indicated.
• Although there are no data to support a threshold for
treatment of hypotension in stroke patients
• we recommend treatment for signs of dehydration,
blood pressure that is substantially below the
expected level for a given patient (consider past
history of hypertension, treated or untreated), or both.
Chronic Management of Blood
Pressure After Stroke
Pedelty, Laura; Gorelick, Philip B.
From the Department of Neurology and
Rehabilitation, University of Illinois at
Chicago.
When Is it Safe to Administer Blood
Pressure Lowering Therapy After Stroke?
• There remain no definitive data to
guide decisions regarding this issue
• discussion with experts suggests that
the optimum time period for starting
antihypertensive therapy after acute
stroke may be as early as 7 days and as
long as a month or more.
What Is the Target BP Goal, and How
Soon Should This Goal Be Reached?
• A precise target blood pressure goal for prevention of
recurrent stroke has not been established according
to clinical trial data.
• HOPE, blood pressure was lowered by [almost equal
to]3/2 mm Hg in the ramipril treatment group
compared with placebo : ramipril 10 mg PO daily
provided no statistically significant benefit in
patients with previous stroke/TIA
• The Captopril Prevention Project trial demonstrated
that captopril lead to an increased risk for stroke
compared to diuretics, b-blockers, or both
What Is the Target BP Goal, and How
Soon Should This Goal Be Reached?
• PROGRESS:
• Perindopril Protection Against Recurrent
Stroke Study
• was a randomized, double-blind, placebocontrolled trial conducted at 172 centers in
Asia, Australasia, and Europe.
• Perindopril-based therapy reduced the
overall risk of major vascular events
Perindopril
• (1) it has a long duration of action,
providing smooth 24-hour blood
pressure control from a once-daily dose;
• (2) it has a minimal first-dose effect;
• (3) it does not compromise cerebral
blood flow.
PROGRESS
• In conclusion, blood pressure–lowering therapy is
now established as the most important measure for
primary and secondary stroke prevention.
• Results of PROGRESS suggest that antihypertensive
treatment with a combination of perindopril plus
indapamide should now be routinely considered for
all patients with previous stroke or TIA.
• The PROGRESS results support blood pressure–
lowering therapy for secondary stroke prevention,
not only for patients with hypertension, but also for
nonhypertensive individuals
PATS--1995
• PATS Post-stroke Antihypertensive
Treatment Study
• 5665 patients in China
• Previous stroke or TIA
• Average BP 154/93 mmHg
• Mean age 60 years
• FU 2 years
• BP reduction 5/2
• reduction 1st fatal/nonfatal stroke by 29%
What Is the Target BP Goal, and How
Soon Should This Goal Be Reached?
• In the absence of large-scale clinical trial data
needed to help establish blood pressure
lowering targets for prevention of recurrent
stroke, utilization of the 7th report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure (JNC 7) targets seems reasonable.
• This translates to a target blood pressure of
<140/90 mm Hg for most stroke patients and
<130/80 mm Hg for patients with diabetes
mellitus or chronic kidney disease.
COSSACS
• Continue Or Stop post-Stroke
Antihypertensives Collaborative Study
Robinson TG, Potter JF
18 October 2002.
http://www.le.ac.uk/cv/research/COSSACS/COSSACShome.html
Membership
• Professor Christopher BULPITT
Professor of Geriatric Medicine, Imperial College School of Medicine
• Professor Gary FORD
Professor of Pharmacology of Old Age, University of Newcastle-Upon-Tyne
• Dr Joanne KNIGHT
Associate Director of Research and Development, Stroke Association
• Professor John POTTER (Co-Principal Investigator)
Professor Of Medicine for the Elderly, Leicester Warwick Medical School
• Professor Neil POULTER (Chairman)
Professor of Preventative Cardiovascular Medicine, Imperial College School of
Medicine
• Dr Thompson ROBINSON (Co-Principal Investigator)
Senior Lecturer in Medicine for the Elderly, Leicester Warwick Medical School
• Professor Carol JAGGER (Trial Statistician)
Professor of Epidemiology, University of Leicester
• 2005/9/30
COSSACS
Study Design and Objectives
• Up to 40% of acute stroke patients on hospital admission are already
taking antihypertensive therapy
•
However, no guidelines exist as to whether antihypertensive therapy
should be continued or discontinued following acute stroke.
• United Kingdom based Multi-centre, prospective, randomised, open,
blinded-endpoint trial.
• Antihypertensive therapy should be continued or discontinued within
24 hours of stroke onset and for the subsequent two weeks.
• The trial will assess the short- (2 weeks) and long-term (6 months) rates
of death and disability in the continued versus discontinued groups,
and provide information to support the future evidence-based
management of acute post-stroke hypertension.
COSSACS
Early Endpoints
• Neurological deterioration (NIHSS).
• Functional status (Barthel Index).
• BP changes (admission to 2 weeks).
• Serious Adverse Events.
COSSACS
Late Endpoints
• Death.
• Dependency (Modified Rankin Score).
• Fatal and non-fatal stroke recurrence.
• Health-related quality of life
– IST questionnaire
– EuroQOL
• Place of Residence.
References
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http://64.233.167.104/search?q=cache:AHHtMCYa8i4J:www.informedpharmac
otherapy.com/Issue11/EBP/Mysak%2520T%2520EBP%25202002%252011.htm+
Post-stroke+antihypertensive&hl=zh-TW
http://qjmed.oupjournals.org/cgi/content/full/92/2/63
http://www.ninds.nih.gov/health_and_medical/stroke_proceedings/brodrick.
htm#table%201
http://www.aafp.org/afp/990515ap/2828.html
http://home.mdconsult.com/das/journal/view/400672712/N/13534287?ja=358038&PAGE=1.html&sid=292447848&source=MI
http://www.le.ac.uk/cv/research/COSSACS/COSSACShome.html
Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996
Trials on blood pressure-lowering and secondary stroke prevention.
The end