HYPERTENSION MANAGEMENT IN - EMCREG-International

ADVANCING THE STANDARD OF CARE:Cardiovascular and Neurovascular EmergenciesMore compelling inmost patients, however,is the concern thataggressive loweringof blood pressure cancause a reduction ofperfusion in the areaof ischemia, which mayexpand the region ofinfarction.in survivability that come with decreasesand increases in blood flow respectively.Thus it is clear that even relatively briefperiods of even relative hypotension mustbe avoided to prevent marked increase ininjury. 4The best summary statement regardingblood pressure management in thesetting of ischemic stroke comes fromthe American Stroke Association’s mostrecent guidelines on the managementof ischemic stroke. The authors state:“Despite the prevalence of arterialhypertension following stroke, its optimalmanagement has not been established.” 5Thus for all ischemic stroke patients,a blanket recommendation is not yetpossible. Clinicians must considerwhat factors should influence treatmentdecisions and then act on a case by casebasis.100Theoretical reasons to consider loweringa patient’s blood pressure include thepotential to reduce the formation of brainedema, lessening the risk of hemorrhagictransformation, and preventing furthervascular damage. More compelling inmost patients, however, is the concern thataggressive lowering of blood pressure cancause a reduction of perfusion in the areaof ischemia, which may expand the regionof infarction. This is well documentedin the literature with adverse clinicaloutcomes with sublingual nifedipine. 6Current expert consensus is that potentialindications for acute reduction of elevatedblood pressure in the setting of acuteischemic stroke include: patients whoare candidates for fibrinolysis to reducethe risk of hemorrhage, patients withsignificant end organ damage (e.g. acuteNRNeurologic Injury (%)755025ET50CR00 100 200 300 400 500Duration of Ischemia (min)Figure 3. Degree of injury in compromised tissue based onperfusion changes. Adapted with permission from Zivin et al.Neurology 1998;50:599-603.64w w w . e m c r e g . o r g