Blood Pressure Control after Cerebrovascular Accident

1. See Also
   1. Cerebrovascular Accident
   2. Hypertensive Crisis
2. Precautions
   1. Blood Pressure management described here is for ischemic Cerebrovascular Accident only
      1. Hemorrhagic CVA (e.g. Subarachnoid Hemorrhage) targets a lower Blood Pressure
   2. Avoid lowering Blood Pressure too low in acute CVA
      1. Lower Blood Pressure correlates with lower perfusion
         1. Hypothesized that in chronic Hypertension, the brain acclimatizes to higher perfusion changes
         2. Abruptly lowering Blood Pressure risks worsening cerebral ischemia
         3. Goal Blood Pressure: 120% of baseline Blood Pressure
      2. Lowering Blood Pressure in acute Ischemic Stroke does not improve outcomes (outside of CVA Thrombolysis or sbp>220 mmHg)
         1. He (2014) JAMA 311(5): 479-89 [PubMed]
         2. Sandset (2011) Lancet 377(9767):741-50 [PubMed]
3. Management: Fibrinolytic candidates
   1. Pre-fibrinolytic
      1. Indications for lowering Blood Pressure prior to fibrinolytic
         1. SBP >185 mmHg or DBP >110 mmHg
         2. BP sustained >185/110 mmHg despite pre-fibrinolytic measures listed will contraindicate Thrombolysis
      2. Preparations
         1. Labetalol 10-20 mg IVP x1-2 doses or
         2. Nitropaste 1-2 inches or
         3. Nicardipine infusion 5 mg/h titrated by 2.5 mg/h increments (maximum 15 mg/h) or
         4. Enalapril 1.25 mg IVP
   2. Post-fibrinolytic
      1. DBP >140 mmHg
         1. Sodium Nitroprusside 0.5 mcg/kg/min
      2. SBP >230 mmHg or DBP 121-140 mmHg
         1. Labetalol 10-20 mg IVP over 1-2 minutes and
         2. Consider Labetalol infusion at 2-8 mg/min
      3. SBP 180-230 mmHg or DBP 105-120 mmHg
         1. Labetalol 10 mg IVP and
         2. May repeat and double Labetalol dose every 10-20 min (up to maximum of 150 mg)
4. Management: Non-fibrinolytic candidates
   1. DBP >140 mmHg
      1. Sodium Nitroprusside 0.5 mcg/kg/min
   2. SBP >220 mmHg or DBP 121-140 mmHg or MAP >130 mmHg
      1. Labetalol 10-20 mg IVP and
      2. May repeat and double Labetalol dose every 10-20 min (up to maximum of 150 mg)
   3. SBP <220 mmHg or DBP 105-120 mmHg or MAP <130 mmHg
      1. Antihypertensive therapy indicated if:
         1. Acute Coronary Syndrome
         2. Aortic Dissection
         3. Severe Congestive Heart Failure
         4. Hypertensive Encephalopathy
         5. Retinal Hemorrhage
         6. Acute Renal Failure
      2. Protocol
         1. Lower Blood Pressure by up to 15% gradually titrating while observing for worsening neurologic changes
         2. See preparations listed above under pre-fibrinolytic
5. Monitoring: Vital Signs
   1. Response to Blood Pressure in CVA following Fibrinolysis should be per above guidelines and prompt
   2. Initial: Every 15 minutes for 2 hours
   3. Next: Every 30 minutes for 6 hours
   4. Next: Every 1 hour for 16 hours
6. Preparations: Antihypertensives to consider following acute phase of CVA Management
   1. Labetolol 200-300 PO bid to tid
      1. Relatively contraindicated in Asthma, Congestive Heart Failure, Arrythmias
      2. Consider Labetalol IV if refractory to oral measures
   2. Nifedipine 10 mg PO q6h
   3. Captopril 6.25-25 q8h
   4. Nicardipine
      1. Used in Subarachnoid Hemorrhage
   5. Nimodipine 60 mg PO q4h
      1. Used in Subarachnoid Hemorrhage
   6. Angiotensin Receptor Blocker (ARB)
      1. Started on day 1 if Hypertension with Ischemic CVA
         1. Two BPs >200/100 at 6 to 24 hours post-CVA or
         2. Two BPs >180/105 at 24 to 36 hours post-CVA
      2. Significantly reduced recurrent CVA risk
         1. Schrader (2003) Stroke 34:1699-703 [PubMed]
7. References
   1. Lisk (1993) Arch Neurol 50:855-62 [PubMed]
   2. Powers (1993) Neurology 43:461-7 [PubMed]