Blood pressure management in acute stroke

council members late afternoon first its

honor and the pleasure to be invited

here I'm representing the ESC Council of

hypertension and as we have already

discussed hypertension and atrial

fibrillation and stroke has a close

relation my disclosures all outside the

presented work and what I would like to

cover in these 10 or 12 minutes is

basically hypertension in acute stroke

some things are clear some things are

unclear and I will cover first of course

hypertension is made a risk factor for

hemorrhagic an ischemic stroke we all

know that we all also know the pituitary

is often elevated at presentation with

acute stroke but it often declines

without intervention so we can just wait

and see if we have the acute hemorrhagic

stroke an increased blood pressure is

very common it is associate with

hematoma expansion with increased

mortality with worse prognosis of

neurological recovery and also with

impaired dependency in ischemic stroke

as compared to hemorrhagic one in the

same dr. pressure is elevated in most

patients but it often decreases already

within hours and unfortunately the blood

pressure management during the acute

phase of hemorrhagic stroke remains

uncertain and the benefit for treating

endemic stroke is even less clear

finally hypertension is a risk factor

for recurrent stroke but optimal blood

pressure target in secular prevention is

not really well-established and just a

few slight of these different issues

first acute intracerebral hemorrhage

this is the interact to study which I


on top of the slide I'm sorry about that

in this study as you may know immediate

blood pressure lowering to below 140

within an hour and maintained for a week

or standard treatment which was then

lowering blood pressure to below 180

millimeters of systolic blood pressure

it was done in some 3,000 patients and

the bottom findings are that sorry

the primary outcome with which was death

or major disability was not

significantly different secondary

outcomes in terms of ranking scale and

health-related quality of life tended to

be improved with stronger or quicker

bhavish reduction and mortality was

similar so the conclusion from this

study is that treatment is feasible it

is safe and it's modest function if you

go to the other study with a similar

layout which is it actually actually

these authors managed to reduce blood

pressure strongly here and you see the

two groups although the aim was the same

as in the previous study the blood

pressure lowering was strong within the

first day or two here the primary

outcome which again was death or

disability was not significantly

different but there was a trend for

reducing hematoma expansion and there

was a trend or weak significance for

more serious adverse events if your

lower blood pressure more quickly so the

conclusion for this study would be that

there is no effect on the primary

outcome but there are more adverse

events at least renal adverse events

within the first week so if you try to

summarize these studies on the

management in interesting there's a

hemorrhage and this is taken from the

American hyper

and guidelines just a year old I think

they nicely summarized that if you have

an acute average presenting within six

hours if you have a blood pressure above

to 20 millimeters of mercury

there is some evidence that you should

lower the pressure by intravenous drugs

and close blood pressure monitoring it's

a class 2a recommendation but if you

have a blood pressure below 1/4 to 20

millimeters a systolic there is actually

no benefit and there is a potential harm

in adverse effect this may be a

conservative interpretation of the data

but this is how the Americans at least

interpret the data if we move them to

ischemic stroke the fact is that the

potential benefit of blood pressure

reduction in the acute phase is it less

clear than in acute inter cerebral

hemorrhage but here a key consideration

is whether the patient will receive

thrombolytic therapy or not of course

and there are observational studies

reporting that increased risk of

intracerebral hemorrhage with

thrombolysis is present if you have a

markedly elevated blood pressure not

surprisingly but again the benefit of

blood pressure lowering is uncertain

this is a recent publication came out

last year on a watch american Registry

of some 3,300 thousand patients with

ischemic stroke and I think it clearly

shows that the relation on outcome and

admission blood pressure is J shaped

that goes for

that goes for mortality for discharge

not to home for independancy or for

complications of thrombolytic therapy so

there is a j-shaped curve that is true

for systolic blood pressure and also on

your right hand side for diastolic blood

pressure the next slide from the same

registry shows something that I think is

forgotten often and that is the relation

with pulse pressure and as you see again

there is a relation with pulse pressure

and pulse pressure is cheap but rather a

nice way of evaluating

Artic stiffness so if you have stiff

stiff vessels you have large pulse

pressures and then you of course have

high risk of complications because

otherwise diastolic blood pressure is

not really the problem for bleeding but

a local diastolic blood pressure and a

high systolic pressure then you have

stiff arteries and then you have high

risk but pulse pressure seems to be too

simple to be used by clinicians today

this is a meta-analysis now three years

ago on blood pressure lowering and I'll

come in ischemic stroke I'm sorry that

it's not perfectly clear copy of the

publication the bottom line here is that

if you look into short-term or long-term

dependency there is absolutely no effect

if you look into prominent or slower

blood pressure reduction on your right

hand side if you look on short-term or

long-term mortality again it is the

similar outcome whether you have

intensive or standby pretreatment and in

these studies the average difference

here was eight over four millimeters of

mercury again suggesting that blood

pressure lowering in

cute ischemic stroke may not have

influence on dependency or mortality

summarizing again than in ischemic

stroke again the American guidelines

here on your right is the summary flow

chart here showing that if you have a

blood pressure that is high it is sorry

if you have a case where you intend to

give some politically repiy you have to

reduce blood pressure to below 180 over

one pen or one fight and that should be

done and there is evidence for that if

you don't treat patients with

thrombolytic therapy and you have very

high blood pressures there is some

evidence to have a slow and careful

blood pressure reduction but if you have

blood pressures below 220 then the

evidence is weak and there is potential

harm to do this because of adverse

events so talking about drugs for IV

treatment I just want to promote this

consensus document that was written by a

few of the ESC Council came out earlier

last year at the SC Congress on

hypertensive emergencies and I think

it's quite useful that there is a table

and extensive table with intravenous

drugs available in Europe that can be

used in hypertensive emergencies and for

the case of stroke the literature seems

threatened and either labetalol or Nick

or the pain because these are the drugs

that have been used but probably the

point is to reduce blood pressure and

not really by which rod but these seems

to be the drugs most populated mostly

recommended because of their use in

stroke patients

I think a few words about blood

pressure's reduction and secondary

stroke prevention this is again a recent

meta-analysis from Greece by Katsaros

showing that in a dozen or so of

randomized control studies on anti heart

beat as the treatment secondary

prevention there is a relation between

achieved systolic blood pressure and

outcome whether it's becoming stroke

myocardial infarction cardiovascular

death or all cause mortality so the

lower the blood pressure basically the

better the prognosis in secondary

prevention and this means that in

secondary prevention we may summarize

the evidence again using the American

guidelines here that if you have a

stroke and you consider secondary

prevention if the patient is hypotensive

you should start again with blood

pressure lowering therapy not

immediately but within a few days if

this patient has no known hypertension

but appears to have an elevated blood

pressure here defined as 140 90 or more

initiate antihypertensive therapy if

blood pressure is lower then there is no

evidence to do this target blood

pressure here is suggested to be below

130 over 80

the evidence is rather weak it's to be a

recommendation from the American

associations so this is my summary slide

this is the European Society of

Cardiology and European Society of

hypertension guidelines on hypertension

nice-enough they are by and large very

similar to the American recommendations

and as you see they start up with acute

intra cerebral hemorrhage immediate

blood pressure lowering is not

recommended for patients with a systolic

blood pressure below 220 it's a class

three level a so it's a strong

recommendation if the patient has a

blood pressure higher or equal to 220

therapy should be considered to go below

180 in ischemic stroke patients routine

blood pressure lowering is not

recommended with the following

exceptions and that is and patients

eligible for trumbo lytic therapy we're

below 180 over one five for at least 24

hours is recommended and in patients

with markedly elevated blood pressure

and that is 220 or higher care for blood

pressure reduction should be considered

but then about the 15% reduction during

the first 24 hours which is slow in

patients with an acute event treatment

is recommended these are strong

recommendations in a CIA immediately

after Islamic stroke several days

similar basically to what we heard about

and cannot repeat and target blood

pressure according to the European

guidelines or the same as for all other

patients that is 120 to 130 over 70 to

80 millimeters of mercury and the matter

is blood pressure but a Ross blocker and

the calcium channel blocker or fi side

should be part of the recommended drug

regimen according to the European

recommendations and with this I thank

you for your