Cardiovascular Critical Care II
| (c) | Treatment should occur only if (1) thrombolytic therapy is required (goal SBP less than 185 |
|---|
mm Hg and DBP less than 110 mm Hg before thrombolysis initiation - has been shown to
decrease risk of bleeding), (2) other target organ damage occurs, or (3) SBP is greater than
220 mm Hg and/or DBP is greater than 120 mm Hg (Stroke 2013; 44: 870-947).
| (d) | If treatment in indicated (outside of thrombolytic goal stated above): goal 10%–20% MAP |
|---|
reduction over 24 hours (Cardiol Clin 2012;30:533-43; CNS Drugs 2015; 29: 17-28).
iii.
Intracerebral hemorrhage
| (a) | BP reduction goals will be based on individual factors, including medical history; ICP, |
|---|
if known; demographics such as age; presumed cause of hemorrhage (e.g., arteriovenous
malformation); and interval since onset.
| (b) | High BP is associated with worse outcomes, including hematoma expansion, neurological |
|---|
deterioration, death, and inability to perform activities of daily living after intracranial
hemorrhage (Eur J Neurol 2013;20:1277-83; Stroke 2013;44:1846-51; J Hypertens
2008;26:1446-52).
| (c) | BP reductions in patients without ICP elevations to goal SBP targets of less than 140 |
|---|
mm Hg and/or less than 160 mm Hg have been shown to be safe and may confer benefit
regarding functional recovery (Stroke 2013;44:1846-51; Stroke 2012;43:2236-8; Arch
Med 2013; 368: 2355-2365). In a study evaluating an early (within 6 hours) intensive care
bundle that included the early intensive lowering of systolic blood pressure (target less
than 140 mm Hg), strict glucose control in those without diabetes, antipyrexia treatment
(target body temperature less than or equal to 37.5°C), and rapid reversal of warfarin-
related anticoagulation (target international normalized ratio less than 1.5) within 1 hour,
40). Although promising, given the bundled nature of the intervention, it is hard to know
what portion of the care bundle was driving the benefits seen.
| (d) | It is unclear whether aggressive targets are safe in patients with extreme elevations in |
|---|
BP (i.e., SBP greater than 220 mm Hg), patients with large hematomas, or those with
elevations in ICP. Aggressive therapy can be considered, though a more modest reduction
to an SBP less than 180 mm Hg or a MAP less than 130 mm Hg over the first 24 hours is
recommended (Stroke 2015;46:2032-60).
Agents for BP management of hypertensive emergency
The drugs of choice for many presentations of hypertensive emergency are intravenous nicardipine
or nitroprusside (Neurology 2014;83:1523-9; Curr Hypertens Rep 2014;16:450; High Blood Press
Cardiovasc Prev 2022;29:33; Hypertension 2020;75:1334-57).
Intravenous nitroprusside works rapidly and is safe in the presence of renal and/or hepatic
impairment for short-term use (24 hours or less).
ii.
Continuous BP monitoring (e.g., arterial line) is recommended with use because rapid changes
can occur.
iii.
Nitroprusside can increase ICP and may result in coronary steal; caution or avoidance should
be considered in patients with elevated ICP and acute myocardial ischemia/infarction.