MANAGEMENT OF

HYPERTENSION IN

ACUTE STROKE

DR SUDHIR KUMAR MD DM (NEUROLOGY)

CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD

INTRODUCTION

• Stroke is among the three leading causes of death (other two are heart attacks and cancer)

• Stroke can be classified into two types- ischemic and hemorrhagic.

• Majority of the strokes (60-70%) are ischemic and the rest are of hemorrhagic type.

• Hypertension is the leading modifiable risk factor for both types of stroke.

• Appropriate control of blood pressure is required to ensure good outcome in patients with stroke.

• Adequate BP control is also needed to prevent recurrence of stroke.

HT AS A RISK FACTOR

FOR ACUTE ISCHEMIC

STROKE

• People with HT are four times more likely to suffer from

stroke (as compared to those without HT),

• Higher the BP, higher is the risk of stroke (10mmHg

increase in SBP increases stroke risk by 38%),

• Lower BP reduces the risk of stroke, as compared to mild

HT (RR 0.50 at BP 136/84 mmHg, and 0.35 at BP of 123/76

mmHg),

• HT is identified as a risk factor in about 66% of patients

with first ever ischemic stroke (either self-reported history

of HT or admission BP>160/90 mmHg).

IMPACT OF HT ON

ISCHEMIC STROKE

SUBTYPE

• HT is the commonest risk factor for all stroke

subtypes,

• HT is strongly associated with small artery

occlusions and lacunar infarcts,

• Hypertensive patients have more cerebral white

matter lesions on MRI. Presence of these

findings predict a later occurrence of ischemic

stroke,

• Arteriosclerosis of penetrating brain vessels is

involved in the pathogenesis of white matter

lesions.

MANAGEMENT OF HT IN

PATIENTS WITH ACUTE

ISCHEMIC STROKE (AIS)

• Elevated BP is present in >80% of patients with AIS,

• Aggressive lowering of BP may lower cerebral perfusion

pressure (CPP), thereby aggravating brain ischemia,

• Very high BP, on the other hand, can worsen cerebral

edema, resulting in poorer outcomes,

• Extreme HT can also lead to encephalopathy, cardiac

complications and renal insufficiency.

• Case fatality in AIS follows a U shaped curve with regards

BP: higher death rates at too low or too high BP,

• Best outcomes are observed at SBP between 140-180

mmHg.

HT MANAGEMENT IN

AIS (2)

• Early death increases by 18% for every 10 mmHg drop in

SBP below 150 mmHg; and by 3.8% for every 10 mmHg

rise in SBP above 150 mmHg.

• In a recent study, higher admission BP was associated

with milder strokes, and lower admission BP was

associated with severe strokes. This could be due to the

protective effect of higher BP due to increase in CPP.

• BP lowering in acute phase does not reduce death or

dependency.

BP TARGETS IN ACUTE

ISCHEMIC STROKE

• Antihypertensive medications are

withheld, as long as SBP is 220 mmHg or

lower and DBP is 120 mmHg or lower,

• In stroke patients undergoing IV

thrombolysis with alteplase or

tenecteplase, anti-hypertensive drugs are

not used if the SBP is 185 mmHg or lower

and DBP is 110 mmHg or lower.

ANTIHYPERTENSIVE

AGENTS OF CHOICE IN

FIRST 24 HRS AFTER AIS

1. Labetalol: 10-20 mg IV over 1-2 min; may

repeat one more time,

2. Nicardipine: 5 mg/hr IV; titrate up by 2.5

mg/hr every 5-15 min (maximum 15

mg/hr)

3. For persistent raised BP, labetalol

infusion 2-8 mg/min may be used.

INDUCED HT AS A TREATMENT

STRATEGY IN AIS

• HT in the first 24 hours may be beneficial as it improves

CPP,

• Small studies have used phenylephrine or norepinephrine

in the first 24 hours to keep the BP high normal or mildly

high,

• Studies showed improvement in ischemic deficits

including aphasia,

• Improved perfusion was also noted on MR perfusion

studies,

• Treatment appears promising, however further larger trials

are needed. Not included in guidelines yet.

BP TARGETS FOR

STROKE PREVENTION

• <140/90 mmHg for uncomplicated

hypertensive patients,

• <130/80 mmHg for those with

diabetes mellitus or chronic kidney

disease.

• <130/80 mmHg for those with recent

lacunar stroke.

PREFERRED ANTIHYPERTENSIVE

DRUGS FOR SECONDARY STROKE

PREVENTION

CLASS OF DRUG DRUG EFFICACY

ACE inhibitor Perindopril, Ramipril Effective

Diuretic Indapamide Effective

ARB Losartan Effective

ARB Telmisartan Possibly Effective

Ca channel blocker Amlodipine Effective

Beta blocker Atenolol Not effective

HYPERTENSION

AND

HEMORRHAGIC

STROKE

HT AS A CAUSE FOR

HEMORRHAGIC STROKES

• HT alone or in combination with risk factors accounts for

80% of ICH cases,

• Odds ratio for developing ICH in patients with HT is 3.7,

• The risk of developing ICH increases with increasing

severity of HT,

• RR 2.2 for high normal BP, 5.3 for stage 1 HT, 10.4 for

stage 2 HT and 33 for stage 3 HT

• RR 2.2 for SBP of 140-159 mmHg, 3.8 for >160 mmHg as

compared to SBP<140 mmHg.

EFFECTS OF HT ON

ACUTE ICH

• Hematoma expansion is more common in hypertensive

ICH, as compared to ICH due to cerebral amyloid

angiopathy (45% vs 19%),

• Neurological deterioration is more common in patients

with hematoma expansion,

• Cerebral edema and perihematomal edema are also more

in patients with higher BPs,

• Higher BPs lead to higher death rates. 28-day survival

rates with MAP of 118 mmHg or less, 119-132 mmHg, 132-

145 mmHg and >145 mmHg were 71%, 65%, 60% and 30%,

respectively.

BP CONTROL IN

ACUTE ICH

• BP lowering is the single most important

predictor for better outcome in acute ICH,

• Intensive BP lowering is associated with

better functional outcomes at 90 days

after ICH.

• This is in contrast to Ischemic stroke,

where BP lowering is avoided in the first

24 hours.

BP TARGETS IN

ACUTE ICH

• For ICH patients with SBP between 150-220 mmHg and

without a contraindication to acute BP treatment, acute

lowering of BP to 140 mmHg is safe (Class I; Level of

evidence A) and can be effective for improving functional

outcome (Class IIa; level of evidence B)

• For ICH patients presenting with SBP>220 mmHg,

aggressive BP lowering with a continuous IV infusion may

be considered (Class IIb; Level of evidence C)

• Both nicardipine and labetalol infusion are equally safe

and effective.

BP CONTROL IN ICH

PATIENTS POST

DISCHARGE

• Patients with hypertensive ICH have a higher rate of

recurrence of ICH (9% at 1 year, and 14% at 5 years),

• Target BP of 130/80 mmHg or lower is recommended to

prevent recurrence of ICH.

• There is no specific recommendation regarding the choice

of antihypertensive agent, and it depends on age,

comorbid conditions such as DM, renal insufficiency,

cardiac disease, etc.

CONCLUSIONS

• HT is an important risk factor for both acute ischemic

stroke (AIS) and acute intracerebral hemorrhage (ICH),

• BP lowering is generally avoided in the first 24 hours in

AIS,

• Target BP is 220/120 mmHg in non-thrombolysed, and

185/110 mmHg in thrombolysed patients with AIS,

• In acute ICH, intensive BP lowering is beneficial. Target BP

is 140 mmHg or lower,

• Labetalol or Nicardipine are the preferred agents,

• BP control is also important to reduce the future

recurrence of strokes.

COMMENTS/QUERIES?

drsudhirkumar@yahoo.com

https://www.facebook.com/bestneurologist/

https://bestneurodoctor.blogspot.in

This talk was presented at 27th BPCON 2017 on

Sep 3rd at New Delhi