HYPERTENSION MANAGEMENT IN - EMCREG-International

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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
HYPERTENSION MANAGEMENT INACUTE NEUROVASCULAR EMERGENCIESmyocardial infarction, aortic dissection, hypertensiveencephalopathy, acute renal failure, acute pulmonaryedema, etc.), or patients with extremes of blood pressure(systolic above 220 or diastolic above 120). 5The clearest indication for blood pressure lowering inthe setting of acute ischemic stroke is in patients whoare candidates for fibrinolytic therapy. In this population,elevated blood pressure significantly increases the risk ofintracerebral hemorrhage. Fibrinolytic therapy should notbe given to patients who have a systolic blood pressure>185 mm Hg or a diastolic blood pressure >110 mm Hg atthe time of treatment. 5,7 Often stroke patients arrive withvery elevated blood pressure, but it may fall within theseparameters after a few minutes without specific therapy. Ifnot, guidelines for fibrinolytic therapy allow for treatmentof the blood pressure with relatively modest measures,including intravenous labetalol boluses, enalaprilatand some centers are now using nicardipine infusion.However, very aggressive interventions to lower bloodpressure should not be used, so if the above measuresare not effective in achieving the blood pressure targets,then fibrinolytic therapy is contraindicated. If the patientis treated with a fibrinolytic, the blood pressure must bemaintained
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HYPERTENSION MANAGEMENT IN - EMCREG-International

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