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