Cardiovascular Medicine Book

Hypertension

  • Blood Pressure Control after Cerebrovascular Accident

http://www.fpnotebook.com/

Blood Pressure Control after Cerebrovascular AccidentAka: Stroke Related Blood Pressure Management, CVA Blood Pressure Control

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  1. General
    1. Avoid lowering Blood Pressure too low in acute CVA
      1. Lower Blood Pressure correlates with lower perfusion
    2. Goal Blood Pressure: 120% of baseline Blood Pressure
  2. Absolute indications for BP intervention in acute CVA
    1. Blood Pressure >220/120
    2. Acute Myocardial Infarction
    3. Hypertensive encephalopathy
    4. Renal Failure
    5. Aortic Dissection
    6. Retinal hemorrhage
  3. Emergent Hypertensive Crisis
    1. Criteria
      1. Diastolic Blood Pressure exceeds 140 mmHg
      2. Confirmed on 2 readings, 5 minutes apart
    2. Management
      1. Start Nitroprusside Infusion
  4. Severe Hypertensive Crisis
    1. Criteria
      1. Systolic Blood Pressure >230 or
      2. Diastolic Blood Pressure 121 to 140
      3. Confirmed on 2 readings, 20 minutes apart
    2. Management
      1. Labetolol 20 IV over 1-2 minutes
        1. May repeat dose or double dose every 10-20 minutes
        2. Subsequent Labetolol doses given every 6-8 hours
      2. Endpoints
        1. Satisfactory Blood Pressure
        2. Maximum dose reached of 300 mg Labetolol
      3. Relative contraindications
        1. Asthma
        2. Congestive Heart Failure
        3. Arrythmias
  5. Moderate Hypertensive Crisis
    1. Criteria
      1. Systolic Blood Pressure 180 to 230 or
      2. Diastolic Blood Pressure 105 to 120 and
      3. Signs of end-organ consequences
        1. Subarachnoid Hemorrhage or
        2. Congestive Heart Failure
      4. Confirm on 2 readings, 60 minutes apart
    2. Management
      1. Labetolol 200-300 PO bid to tid or
      2. Nifedipine 10 mg PO q6h or
      3. Captopril 6.25-25 q8h
      4. Nimodipine 60 mg PO q4h
        1. Used in Subarachnoid Hemorrhage
      5. Labetolol IV
        1. Indicated for refractory to oral interventions
      6. Angiotensin Receptor Blocker (ARB)
        1. Started on day 1 if Hypertension with Ischemic CVA
          1. Two BPs >200/100 at 6 to 24 hours post-CVA or
          2. Two BPs >180/105 at 24 to 36 hours post-CVA
        2. Significantly reduced recurrent CVA risk
          1. Schrader (2003) Stroke 34:1699
  6. Controlled Hypertensive Crisis
    1. Criteria
      1. Systolic Blood Pressure <180 or
      2. Diastolic Blood Pressure < 105
    2. Management
      1. No antihypertensive routinely recommended
      2. Concurrent Heparin use
        1. Carefully titrate down Blood Pressure
        2. Target levels if no prior Hypertension
          1. Systolic Blood Pressure: 150
          2. Diastolic Blood Pressure: 85 to 95
        3. Target levels if prior Hypertension
          1. Systolic Blood Pressure: 160 to 170
          2. Diastolic Blood Pressure: 90 to 100
        4. Benefits of Heparin are very contoversial
          1. DO not rapidly lower BP to start Heparin
  7. References
    1. Lisk (1993) Arch Neurol 50:855
    2. Powers (1993) Neurology 43:461

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