Emergency Medicine is Hard

Hemorrhagic Strokes

• If the presenting BP is between 150 – 220 mmHg, decrease the SBP to ~140 mmHg within the first hour
• If the presenting BP is >220, rapidly decrease BP to <220, and reduce over a period of hours to a SBP between 140 – 160 mmHg

Anti-hypertensives

• If SBP ≥ 160 mmHg, use nicardipine (Cardene) / Clevidipine – fast-acting, titratable
• If SBP < 160 mmHg, use labetalol – ease of administration, long-duration

INTERACT 2 Trial

In the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 (INTERACT2) trial, 2839 patients with acute ICH were assigned (within six hours of symptom onset) either to intensive blood pressure lowering or traditional management (target SBP <140 mmHg versus SBP <180 mmHg). The mean baseline SBP was 179 mmHg. There was a trend toward lower rates of death and severe disability at 90 days with intensive blood pressure lowering, although this was not statistically significant (52 versus 55.6 percent). In addition, intensive blood pressure lowering was associated with improved measures of disability according to modified Rankin scale scores. The rates of acute neurologic deterioration and other adverse events were similar in the patient groups.

ATACH-2 Trial

The Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial found no differences in death or disability rates among 1000 patients with acute ICH assigned in an earlier time window (within 4.5 hours) to a more intensive target SBP of 110 to 139 mmHg versus a standard target SBP of 140 to 179 mmHg (39 versus 38 percent). Additionally, the rate of acute neurologic deterioration in patients assigned to intensive treatment was similar to those assigned standard treatment. However, the rate of adverse kidney events was higher in the intensive treatment group (9 versus 4 percent).

In a post-hoc analysis using individual patient data of the INTERACT2 and ATACH-2 trials, each 10-mmHg reduction in SBP in the first 24 hours was associated with 10 percent increased odds of better functional recovery, down to a threshold as low as 120 to 130 mmHg

Ischemic Strokes

BP Management depends on whether fibrinolytic therapy is indicated

Fibrinolytic therapy indicated – Lower BP ≤ 185/110

Fibrinolytic therapy not indicated – blood pressure should not be treated acutely unless the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg), or the patient has active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, or pre-eclampsia/eclampsia

Anti-hypertensives

• Labetalol 10 to 20 mg intravenously over 1 to 2 minutes
• Nicardipine 5 mg/hour intravenously, titrate up by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour
• Clevidipine 1 to 2 mg/hour intravenously, titrate by doubling the dose every 2 to 5 minutes, maximum 21 mg/hour, until desired blood pressure reached
• Other agents (hydralazine, enalaprilat, etc) may also be considered