post-stroke antihypertensive therapy

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NICE state (1):

Blood pressure control for people with acute ischaemic stroke

  • anti-hypertensive treatment in people with acute stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:

    • hypertensive encephalopathy
    • hypertensive nephropathy
    • hypertensive cardiac failure/myocardial infarction
    • aortic dissection
    • pre-eclampsia/eclampsia

  • blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis

Blood pressure control for people with acute intracerebral haemorrhage

  • rapid blood pressure lowering treatment should be offered to people with acute intracerebral haemorrhage who do not have any of the exclusions listed* and who:
      • present within 6 hours of symptom onset and
      • have a systolic blood pressure between 150 and 220 mmHg
    • aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days
  • consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed * and who:
      • present beyond 6 hours of symptom onset or
      • have a systolic blood pressure greater than 220mmHg
    • aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days

* do not offer rapid blood pressure lowering to people who:

  • have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
  • have a score on the Glasgow Coma Scale of below 6
  • are going to have early neurosurgery to evacuate the haematoma
  • have a massive haematoma with a poor expected prognosis

Notes:

  • there is no definitive evidence as to whether antihypertensive drugs should be started immediately after an ischaemic stroke or if current medication should be continued in the acute post-ictal phase
    • in a study investigating the treatment of hypertension post stroke (patients over 18 years admitted to hospital with a clinical diagnosis of suspected stroke and symptom onset < 36 hours and hypertension, defined as systolic BP (SBP) < 160 mmHg) (2)
      • oral and sublingual lisinopril and oral and intravenous labetalol were effective BP-lowering agents in acute cerebral infarction and haemorrhage and did not increase the likelihood of early neurological deterioration
        • study was not sufficiently powered to detect a difference in disability or death at 2 weeks

Reference:

Last edited 06/2019

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