Acute Hypertensive Response in Patients With Stroke

Abstract

A cute hypertensive response is the elevation of blood pressure (BP) above normal and premorbid values that initially occurs within the first 24 hours of symptom onset in patients with stroke. This phenomenon was reported in Ͼ60% of patients presenting with stroke in a nationally representative study from the United States. 1 With Ϸ980 000 patients 2 admitted with stroke each year in the United States, the estimated annual prevalence of acute hypertensive response is more than half a million patients. With Ϸ15 million patients experiencing stroke worldwide each year, 3 the acute hypertensive response may be expected in Ϸ10 million patients per year. The acute hypertensive response in stroke patients is managed by a diverse group of physicians, including emergency physicians, intensivists, internists, primary care physicians, neurologists, neurosurgeons, and cardiologists. Previous audits suggest that antihypertensive agents and management strategies vary considerably and are not always consistent with recommended guidelines. 4 Data from 1181 acute ischemic stroke patients enrolled in the Project for Improvement of Stroke Care Management suggested that administration of antihypertensive medication within 24 hours in 56% of the patients was inconsistent with guidelines provided by the American Stroke Association (ASA). 5 The present review article summarizes the current concepts pertaining to treatment of the acute hypertensive response derived from recent guidelines provided by professional organizations and "best available" evidence derived from experimental and clinical studies and discusses incorporation of these concepts into clinical practice. Randomized trials, nonrandomized controlled studies, and selected observational studies were identified with multiple searches on Medline from 1980 to 2007 by cross-referencing the key words of stroke, acute hypertension, antihypertensive agents, acute stroke, and hypertension. Pertinent articles identified from bibliographies of selected articles were also reviewed. Treatment targets and strategies were identified by review of existing guidelines from professional organizations. Definition of Acute Hypertensive ResponseThe 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement 6 and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 7 define hypertension on the basis of the presence of consistent BP Ն140/90 mm Hg (multiple readings on separate days). This definition of hypertension is a threshold for the use of long-term antihypertensive treatment that is supported by evidence derived from randomized trials and clinicor population-based data that demonstrate reduction in cardiovascular events with this threshold for treatment. The same definition cannot be applied in the case of acute hypertensive response, because the above-mentioned ascertainment criteria and rationale are not valid. The executive summary of the ISH statement 8 on management of BP i...

Baseline Blood Pressure Effect on the Benefit and Safety of Intra-Arterial Treatment in MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands)

“…Auto regulation at this low level may be disturbed, and required perfusion pressure will probably not be reached. 39 Four patients in MR CLEAN had a BP exceeding 185/110 mm Hg at randomization. Consequently, they should be considered protocol violations.…”

A retrospective pilot study analyzing the effects of various factors and benefits of various drugs used in treating late admitted cases of acute ischemic stroke

“…Most of the patients with severe stroke usually present with very high baseline SBP due to severity of stroke and hence its negative correlation with BI score in subgroup analysis including cases with mNIHSS score >15. 19 Blood pressure level gradually decreases to near normal values after transient rise in initial days of acute stroke. 19 Hence the scenario seen with regard to 'change in SBP' as a factor being positively associated with BI score indicates the pathophysiological process in these patients rather than the effect of blood pressure lowering agents.…”

“…19 Blood pressure level gradually decreases to near normal values after transient rise in initial days of acute stroke. 19 Hence the scenario seen with regard to 'change in SBP' as a factor being positively associated with BI score indicates the pathophysiological process in these patients rather than the effect of blood pressure lowering agents. This could be the reason why there was no significant association between BI score and any of the anti-hypertensive drugs despite the presence of positive association of BI score with amount of 'change in SBP' achieved.…”

Stroke and the emergency medical services – enhancing performance within the chain of survival

“…(Simard et al 2007) Ultimately, the total extent of the infarction is the sum of several pathophysiological existing collateral circulation, the duration of ischaemia before reperfusion occurs variables, such as blood pressure, body temperature and blood glucose level have an during the emergency medical procedures and stroke unit care. (Reith et al 1996, Lindsberg & Roine 2004, Qureshi 2008 …”

“…(Bhalla et al 2000) Stroke patients are frequently hypertensive, which is a sign that can also be used as a clinical clue to distinguish acute stroke from stroke mimics (Gioia et al 2016). Hypertension is thought to be a protective reaction of the human body to secure adequate cerebral perfusion (Qureshi et al 2008). Therefore the blood pressure of the patient is 12-lead electrocardiogram is not required unless simultaneous cardiac symptoms are suspected.…”