When to start antihypertensive after stroke
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
didn't
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
