Hostname: page-component-cd9895bd7-lnqnp Total loading time: 0 Render date: 2024-12-28T03:59:29.303Z Has data issue: false hasContentIssue false
  • English
  • Français

Blood Pressure Management in Acute Stroke: Comparison of Current Guidelines with Prescribing Patterns

Published online by Cambridge University Press:  14 September 2018

Salmann Kanji ,
Céline Corman  and
Andre G. Douen
Salmann Kanji
Affiliation:
Department of Pharmacy, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
Céline Corman
Affiliation:
Department of Pharmacy, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
Andre G. Douen*
Affiliation:
Division of Neurology, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
*
Andre G. Douen, Division of Neurology, The Ottawa Hospital, General Campus, 501 Smyth Rd., Ottawa, ON K1H 8L6 Canada.
Rights & Permissions [Opens in a new window]

Abstract:

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

Current recommendations for treating elevated blood pressure (BP) in the acute stroke are based largely on expert opinion and vary with regard to treatment thresholds and choice of antihypertensive agents. In this study we investigate the influence of these recommendations by comparing the management of hypertension in acute stroke at a tertiary care hospital with current guidelines.

Method:

Retrospective chart review of patients admitted with acute stroke at The Ottawa Hospital-General Campus over six consecutive months. The use of antihypertensive medications (type, dose, routes of administration, BP recordings) in the first seven days after admission was noted.

Results:

Transdermal nitroglycerin paste was the most commonly used antihypertensive agent. In contrast to the 15% reduction in BP over 24 hours recommended for lowering BP in hypertensive patients with ischemic stroke, nitroglycerin caused a >15% reduction of BPover the first 24 hours on 60% of the occasions used. Furthermore, despite concerns about sublingual nifedipine, this was the second most commonly prescribed agent. Surprisingly, the mean time to first BP measurement following initiation of antihypertensive therapy was 117 ± 43 minutes in ischemic stroke and 88 ± 89 minutes in hemorrhagic strokes.

Conclusions:

The current guidelines for management of acute poststroke hypertension appear to have little influence on prescribing patterns, leading to considerable variations in practice. Such variations, likely due to uncertainty caused by lack of evidence from randomised controlled trials, are intolerable as patients maybe submitted to nonstandardised, potentially harmful care such as inappropriate choice of antihypertensives and inadequate BP monitoring as observed in this study.

Résumé:

Résumé:Objectif:

Les recommandations en vigueur pour le traitement de l’hypertension artérielle (HTA) dans l’accident vasculaire cérébral aigu (AVCA) sont basées en grande partie sur l’opinion d’experts et varient quant aux niveaux où un traitement est indiqué et au choix d’agents antihypertenseurs. Dans cette étude, nous évaluons l’influence de ces recommandations sur la pratique en comparant la prise en charge de l’hypertension dans l’AVCA dans un hôpital de soins tertiaires et les lignes directrices en vigueur.

Méthode:

Il s’agit d’une revue de dossiers de patients présentant un AVCA admis à l’Hôpital Général d’Ottawa sur une période de six mois. L’utilisation de médicaments antihypertenseurs (type, dose, voie d’administration, lectures de tension artérielle (TA)) pendant les sept premiers jours après l’admission ont été relevés.

Résultats:

La nitroglycérine administrée par voie transdermique était l’agent antihypertenseur le plus souvent utilisé. Alors que la baisse de la TA recommandée chez les patients hypertendus présentant un AVCAischémique est de 15% sur 24 heures, la nitroglycérine a causé une baisse de plus de 15% de la TAsur 24 heures dans 60% des cas où elle a été utilisée. De plus, malgré les préoccupations quant à l’utilisation de la nifédipine sublinguale, c’était le deuxième agent le plus souvent prescrit. Il était étonnant de constater que l’intervalle moyen entre la première lecture de TA suivant le début de la médication antihypertensive était de 117 ± 43 minutes dans l’AVC ischémique et de 88 ± 89 minutes dans l’AVC hémorragique.

Conclusions:

Les lignes directrices actuelles pour la prise en charge de l’hypertension post AVCA semblent avoir peu d’influence sur le mode de prescription, ce qui entraîne des variations considérables dans la pratique. De telles variations, probablement dues à l’incertitude causée par le manque de données provenant d’études contrôlées randomisées, sont intolérables parce que les patients peuvent être soumis à des soins non standardisés potentiellement nocifs tels des choix inappropriés d’agents antihypertenseurs et une surveillance inadéquate de la TAcomme on l’a observé dans cette étude.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 29 , Issue 2 , May 2002 , pp. 125 - 131
Copyright
Copyright © Canadian Neurological Sciences Federation 2002

References

1. O’Connell, JE, Gray, CS. Treatment of poststroke hypertension: a practical guide. Drugs Aging 1996; 8: 408-415.CrossRefGoogle Scholar
2. Oppenheimer, S, Hachinski, V. Complications of acute stroke. Lancet 1992; 339: 721-724.CrossRefGoogle Scholar
3. Rashid, PA, Bath, PMW. Blood Pressure Management immediately after acute stroke. Stroke Review 2000; 4(2) 1–3.Google Scholar
4. Kenton, EJ. Diagnosis and treatment of concomitant hypertension and stroke. J Natl Med Assoc 1995; 88: 364-368.Google Scholar
5. Bath, PMW. Optimising homeostasis. Br Med Bull 2000; 56(2): 422-435.CrossRefGoogle Scholar
6. Carlberg, B, Asplund, K, Hagg, E. The prognostic value of admission blood pressure in patients with acute stroke. Stroke 1993; 24:1372-1375.CrossRefGoogle ScholarPubMed
7. Robinson, T, Waddington, A, Ward-Close, S, Taub, N, Potter J. The predictive value of 24 hour compared to casual blood pressure levels on outcome following acute stroke. Cerebrovasc Dis 1997; 7:264.CrossRefGoogle Scholar
8. Jorgensen, HS, Nakayama, H, Raaschou, HO, et al. Effect of blood pressure and diabetes on stroke progression. Lancet 1994; 344: 156-159.CrossRefGoogle Scholar
9. Phillips, SJ. Pathophysiology and management of hypertension in acute ischemic stroke. Hypertension 1994; 23: 131-136.CrossRefGoogle ScholarPubMed
10. Tietjen, CS, Hurn, PD, Ulatowski, JA, Kirsch, JR. Treatment modalities for hypertensive patients with intracranial pathology: options and risks. Crit Care Med 1996; 24: 311-322.CrossRefGoogle Scholar
11. Goldstein, LB. Should antihypertensive therapies be given to patients with acute ischemic stroke? Drug Safety 2000; 22:13-18.CrossRefGoogle Scholar
12. Powers, WJ. Acute hypertension after stroke: the scientific basis for treatment. Neurology 1993; 43: 461-467.CrossRefGoogle Scholar
13. Kelley, RE. Blood pressure management in acute stroke. J La State Med Soc 1996; 149: 485-489.Google Scholar
14. The sixth report of the Joint National Committee on Prevention, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 1997; 157: 2413-2446.CrossRefGoogle Scholar
15. Adams, HP, Brott, TG, Crowell, RM, et al. Guidelines for the management of patients with acute ischemic stroke: a statement from a special writing group of the stroke council, American Heart Association. Stroke 1994; 25: 1901-1914.CrossRefGoogle ScholarPubMed
16. Broderick, JP, Adams, HP, Barsan, W, et al. Guidelines for management of spontaneous intracerebral hemorrhage: a statement for health care professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905-915.CrossRefGoogle ScholarPubMed
17. Adams, HP. Acute treatment of cerebral infarction. Therapy in Neurology II. 1995. American Academy of Neurology Annual Meeting. Seattle, Washington, USA. 1995.Google Scholar
18. Broderick, JP. Guidelines for medical care and treatment of blood pressure in patients with acute stroke. In: Marler, JR, Winter Jones, P, Emr, M, eds. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. The National Institute of Neurological Disorders and Stroke; Bethesda, Maryland: December 12-13, 1996; 63-68.Google Scholar
19. Acute candesartan cilexetil stroke survivor (ACCESS) study. Stroke 2001; 32:584.Google Scholar
20. Lisk, DR, Grotta, JC, Lamki, LM, et al. Should hypertension be treated after acute stroke? A randomized controlled trial using single photon emission computed tomography. Arch Neurol 1993; 50: 855-862.CrossRefGoogle Scholar
21. Kaneko, T, Sawada, T, Niimi, T, et al. Lower limit of blood pressure in treatment in acute hypertensive intracranial hemorrhage (AHCH). J Cerebral Blood Flow Metab 1983;3:S51.Google Scholar
22. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-1587.CrossRefGoogle Scholar
23. Brott, T, Lu, M, Cothary, R, et al. Hypertension and its treatment in the NINDS rt-PA Stroke Trial. Stroke 1998; 29:1504-1509.CrossRefGoogle ScholarPubMed
24. Kazui, S, Minematsou, K, Yamamoto, H, et al. Predisposing factors to enlargement of spontaneous intracerebral hematoma. Stroke. 1997; 28:2370-2375.CrossRefGoogle Scholar
25. Qureshi, AI, Wilson, DA, Hanley, DF, et al. No evidence for an ischemic penumbra in massive experimental intracerebral hemorrhage. Neurology 1999; 52:266-272.CrossRefGoogle Scholar
26. Grossman, E, Messerli, FH, Grodzicki, T, Kowey, P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies. JAMA 1996; 276: 1328-1331.CrossRefGoogle Scholar
27. McKindley, DS, Boucher, BA. Advances in pharmacotherapy: treatment of hypertensive crisis. J Clin Pharm Ther 1994; 19: 163-180.CrossRefGoogle Scholar
28. McEvoy, GK, Litvak, K, Welsh, OH, eds. American Hospital Formulary Service Drug Information. Bethesda MD: American Society of Health-System Pharmacists; 1998.Google Scholar
29. Ceyhan, B, Karaaslan, Y, Caymaz, O, et al. Comparison of sublingual captopril and sublingual nifedipine in hypertensive emergencies. Jpn J Pharmacol 1990; 52: 189-193.CrossRefGoogle Scholar
30. Wu, SG, Lin, SL, Shiao, WY, et al. Comparison of sublingual captopril, nifedipine, and prazosin in hypertensive emergencies during hemodialysis. Nephron 1993; 65: 284-287.CrossRefGoogle Scholar
31. Angeli, P, Chiesa, M, Caregaro, L, et al. Comparison of sublingual captopril and nifedipine in immediate treatment of hypertensive emergencies: a randomized, single-blind clinical trial. Arch Intern Med 1991; 151: 678-682.CrossRefGoogle Scholar
32. Gales, MA. Oral antihypertensives for hypertensive urgencies. Ann Pharmacother 1994; 28: 352-358.CrossRefGoogle Scholar
33. Blood pressure in acute stroke collaboration (BASC). Interventions for deliberately altering blood pressure in acute stroke (Cochrane Review). In: The Cochrane Library, Oxford, Update Software, 2001.Google Scholar
34. Dandapani, BK, Suzuki, S, Kelly, RE, Reyes-Iglesias, Y, Duncan, RC. Relationship between blood pressure and outcome in intracerebral hemorrhage. Stroke 1995; 26: 21-24.CrossRefGoogle Scholar
35. Chamorro, A, Vila, N, Ascaso, C, et al. Blood pressure and functional recovery in acute ischemic stroke. Stroke 1998; 29: 1850-1853.CrossRefGoogle ScholarPubMed
36. Horn, J, Limburg, M. Calcium antagonist for acute ischemic stroke (Cochrane Review). In: the Cochrane Library, Oxford: Update Software. Issue 2, 2001.Google Scholar
37. ENOS Investigators, Philip Bath. Efficacy of nitric oxide in stroke (ENOS) trial. Stroke 2000; 31:2885.Google Scholar