Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines*

Qureshi, Adnan I.; Harris‐Lane, Pansy; Kirmani, Jawad F.; Ahmed, S. Sultan; Jacob, Molly; Zada, Yasin; Divani, Afshin A.

doi:10.1097/01.ccm.0000220763.85974.e8

Cited by 71 publications

(41 citation statements)

References 33 publications

(38 reference statements)

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“…SBP is one independent predictor of early neurological deterioration and may be related to an increase in the risk of HE in acute ICH [25, 26]. Therefore, it may be interesting and feasible to study the management of blood pressure in acute ICH patients with sustained very high blood pressure during early assessment [27]. …”

Section: Discussionmentioning

confidence: 99%

Clinical Features Associated with Early Hospital Arrival after Acute Intracerebral Hemorrhage: Challenges for New Trials

Valiente

Alves²,

Silva³

et al. 2008

Cerebrovasc Dis

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Background: Early hospital admission followed by correct diagnosis with minimum delay is a prerequisite for successful new interventions in acute intracerebral hemorrhage (ICH). The aim of this study was to evaluate clinical features associated with early hospital arrival in ICH patients and their influence on the outcome. Methods: Data from all patients arriving within 24 h of the ICH onset were prospectively collected at 2 stroke centers in São Paulo, Brazil. The cutoff of 3 h was chosen to select 2 groups: 0–3 h (early) and >3–24 h (late). Results: We identified 91 ICH patients (mean age 57.9 years, 62% men, 63% white) admitted within the first 24 h of symptom onset between March 2004 and April 2005. Systolic blood pressure, mean arterial pressure and pulse pressure were significantly higher in patients arriving within 3 h. Patients that arrived early also had a higher NIHSS score (p = 0.003), a lower Glasgow Coma Score (p = 0.001) and presence of intraventricular hemorrhage (p = 0.02). Lower ICH scores were more frequent in those that arrived late. Fourteen patients showed hematoma enlargement and the majority of them (n = 13) were admitted within the first 3 h from symptom onset (p = 0.01). Patients who arrived within the 3-hour window had a higher 30-day mortality (p = 0.0008) and a worse Rankin score after 6 months (p = 0.001). Conclusions: Treatment decisions in acute ICH may need to establish new combined approaches to maximize the number of eligible patients for early therapy considering the interactions between independent outcome predictors presented at early onset.

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Section: Discussionmentioning

confidence: 99%

Clinical Features Associated with Early Hospital Arrival after Acute Intracerebral Hemorrhage: Challenges for New Trials

Valiente

Alves²,

Silva³

et al. 2008

Cerebrovasc Dis

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“…Patients treated within 6 hours of symptom onset were more likely to be functionally independent at 1 month than patients who were treated between 6 and 24 hours. Another study 83 evaluated the tolerability and safety of intravenous nicardipine infusion within 24 hours of symptom onset to reduce and maintain MAP Ͻ130 mm Hg, consistent with previous ASA guidelines. The primary outcome of tolerability was achieved in 86% of the patients.…”

Section: Patients With Ichmentioning

confidence: 99%

“…Indirect comparisons suggest that intermittent intravenous bolus regimens of antihypertensive agents have greater variability in BP control than continous infusion regimens. 83 The current ASA 44 and European Stroke Initiative 45 guidelines recommend lowering BP in patients with an ICH to maintain systolic BP below 180 mm Hg. Both guidelines acknowledge that there may be a subset of patients who can tolerate more aggressive BP reduction, such as those with good neurological status or those without chronic hypertension.…”

Section: Patients With Ichmentioning

confidence: 99%

“…The agents that are recommended by the ASA for acute hypertensive response are either intravenous or transdermal agents with rapid onset and short duration of action to allow precise titration (Table 2 42,53,58,[81][82][83][87][88][89][90][91][92][93][94][95][96] ). BP can be monitored adequately with an inflatable cuff in most patients with acute hypertensive response, whereas intra-arterial monitoring should be considered in patients who require frequent titration with intravenous antihypertensive agents and in patients whose neurological status is deteriorating.…”

Section: Antihypertensive Agents and Regimensmentioning

confidence: 99%

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Acute Hypertensive Response in Patients With Stroke

2008

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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...

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“…9) Nicardipine, a calcium-channel blocker and potent vasodilator, is usually used to achieve effective reduction in blood pressure, 8,18) and administration is possible and safe in patients with ICH. 25) Therefore, in our institute, patients with ICH are treated with rapid reduction of SBP using nicardipine.…”

Section: Introductionmentioning

confidence: 99%

Preventive Effect of Aggressive Blood Pressure Lowering on Hematoma Enlargement in Patients With Ultra-acute Intracerebral Hemorrhage

Nishikawa

Ueba

Kajiwara

et al. 2010

Neurol. Med. Chir.(Tokyo)

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The preventive effect of aggressive blood pressure lowering on hematoma enlargement was investigated in patients with ultra-acute spontaneous intracerebral hemorrhage (ICH). Retrospective review of 248 patients (145 males, 103 females) with spontaneous ICH treated in our hospital between 2005 and 2008 identified patients with ultra-acute ICH who were directly taken to our institute by ambulance within 3 hours after onset. Patients who could not be assessed twice by computed tomography (CT) within 24 hours after arrival were excluded. Systolic blood pressure (SBP) was aggressively controlled in all patients using intravenous nicardipine to below 140 mmHg as soon as possible after diagnosis of ICH with CT. Hematoma enlargement was defined as increase in volume of more than 33% or more than 12.5 ml in the first 24 hours. Hematoma enlargement was observed in 11 of the 73 patients (15.0%). The time course of SBP change was not significantly different in patients with and without hematoma enlargement. The incidence of hematoma enlargement in patients with ultra-acute ICH in this study was 15.0%, which was lower than that in other series in which blood pressure was not reduced aggressively. This finding suggests that aggressive SBP lowering to below 140 mmHg has a preventive effect on hematoma enlargement in patients with ultra-acute ICH.

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Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines*

Abstract: We observed a high rate of tolerability among patients with intracerebral hemorrhage who were treated with intravenous nicardipine using mean arterial pressure goals defined by American Heart Association guidelines within 24 hrs of symptom onset.

Cited by 71 publications

References 33 publications

Clinical Features Associated with Early Hospital Arrival after Acute Intracerebral Hemorrhage: Challenges for New Trials

Clinical Features Associated with Early Hospital Arrival after Acute Intracerebral Hemorrhage: Challenges for New Trials

Acute Hypertensive Response in Patients With Stroke

Preventive Effect of Aggressive Blood Pressure Lowering on Hematoma Enlargement in Patients With Ultra-acute Intracerebral Hemorrhage

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