Stroke blood pressure management

Depending upon the location and severity of the stroke at admission, patients may have cardiac and/or respiratory instability at the time of presentation to the emergency department (ED). They may need to be stabilized hemodynamically or intubated for airway protection or respiratory distress. Blood pressure management is often a crucial management issue, and the use of vasopressor or antihypertensive medications is common. In stroke patients at risk for malignant cerebral... 

Lowering blood pressure in patients who are hypertensive has been shown to reduce the relative risk of stroke, both ischemic and hemorrhagic, by 35% to 45%.23 Also, the more blood pressure is lowered, the greater the reduction in stroke risk.24 All patients should have their blood pressure monitored and controlled appropriately based on current guidelines for blood pressure management. However, no one agent has been clearly shown to be more beneficial than any other for preventing stroke. 

Because time is of the essence, it is best if a stroke team that is trained specifically for the triage and treatment of acute stroke patients is formed and appropriate protocols are established. The MGH Acute Stroke Service protocols are listed in Tables 11.1-11.6. They include recommended time targets (Table 11.1) thrombolysis pretreatment phase procedures (Table 11.2) IV-t-PA treatment procedures including inclusion and exclusion criteria (Table 11.3) posttreatment procedures (Table 11.4) details of rt-PA infusion (Table 11.5) and guidelines for blood pressure management in patients receiving this treatment (Table 11.6). 

Blood pressure in the early hours of stroke is above 160/90 mmHg in 80% of patients and generally normalizes without antihypertensive treatment in a majority of them (Oppenheimer and Hachinski, 1992 Phillips, 1994). Acute blood pressure management depends on whether thrombolytic therapy is being administered. 

Hypertension, or a chronic elevation in blood pressure, is a major risk factor for coronary artery disease congestive heart failure stroke kidney failure and retinopathy. An important cause of hypertension is excessive vascular smooth muscle tone or vasoconstriction. Prazosin, an aradrenergic receptor antagonist, is very effective in management of hypertension. Because oq-receptor stimulation causes vasoconstriction, drugs that block these receptors result in vasodilation and a decrease in blood pressure. 

Hypertensive crises are characterized initially by headache, but can evolve to include neck stiffness, chest discomfort, palpitations, confusion, and, ultimately, hemorrhage or stroke. Treatment of MAOI-associated hypertension may include a watch-and-wait stance by the patient if the symptoms are mild. Some patients have the ability to check and monitor their own blood pressure. Others may consult with a physician for blood pressure checks and observation, but if symptoms are severe, the patient may need to go to an emergency room or self-medicate. Standard emergency room treatment is intravenous phentolamine, an a-adrenergic blocker, continuous monitoring and management until blood pressure is normalized without medication. Some doctors will provide patients with small doses of chlorpromazine or nifedipine to treat hypertension if a problem arises. 

Bath FJ, Bath PMW (1997). What is the correct management of blood pressure in acute stroke The Blood Pressure in Acute Stroke Collaboration. Cerebrovascular Diseases 7 205-213... 

The patient should be nursed in a quiet, darkened room. As with other stroke types, the management of raised blood pressure is controversial. 

That s dramatic, especially in view of the current hypertension management guidelines used by physicians that point out that a 5-point reduction in systolic blood pressure can reduce mortality substantially and reduce the risk of stroke by 14 percent and the incidence of coronary heart disease by 9 percent. 

Cardiovascular diseases are a major cause of death in developed countries, making prevention a priority for public health policy. Research evidence over years has shown that cardiovascular diseases can be managed and even prevented by healthful eating practices involving a resveratrol-enriched diet of whole plant foods such as offered by superfruits. For more than fifty years, research has shown that a healthful, active lifestyle combined with the dietary benefit of high fruit and vegetable intake may lower blood lipid levels, blood pressure, and risk of coronary heart disease and stroke. 

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