BP Control and Stroke Pro Calcium Blockers “Melee Mayer” Con Calcium Blockers “Power-Punch Pancioli”

Slides:



Advertisements
Similar presentations
BLOOD PRESSURE MANAGEMENT IN ACUTE STROKE
Advertisements

Hypertension Crisis.
HYPERTENSIVE EMERGENCIES
Hypertensive Emergencies
Emergency Department Patient Hypertensive Emergencies: What treatment modalities do emergency physicians utilize in the ED?
Hyperacute Stroke Treatment: Inclusion and Exclusion Criteria
Hypertension affects > 65 million people in the United States and is one of the leading causes of death One to two percent of patients with hypertension.
Edward P. Sloan, MD, MPH, FACEP Emergency Department Hypertensive Patient Emergencies: Case Presentations and Panel Discussion.
Optimal Management of Hypertensive Emergency Patients: Clinical Scenarios and Panel Discussion.
Scott Silvers, MD, FACEP Treating ED Ischemic Stroke Patients: NIHSS Approximation & Elevated BP Management.
Robert A. Felberg, MD Stroke Program Director Department of Neurology
Blood Pressure Reduction Among Acute Stroke Patients A Randomized Controlled Clinical Trial Jiang He, Yonghong Zhang, Tan Xu, Weijun Tong, Shaoyan Zhang,
Scott Silvers, MD, FACEP Treating ED Ischemic Stroke Patients: NIHSS Approximation & Elevated BP Management.
Edward P. Sloan, MD, MPH, FACEP Emergency Department Patient Hypertensive Emergencies: Published Guidelines, Articles, & Their Findings.
Surgery and hypertension. Presented by: Dr. Rana Chowdhury.
Hypertensive Emergencies Phillip D. Levy, MD, MPH, FACEP Associate Professor Associate Director of Clinical Research Wayne State University Department.
Edward P. Sloan, MD, MPH, FACEP EMRA /FERNE Case Conference: The ED Management of TIA, AIS and ICH Patients.
Beta Blockade and the Heart John Hakim, M.D Cardiology Fellow West Virginia University Division of Cardiology.
Vascular Dysfunction: Sequelae of Acute Hypertension.
Systemic Hypertension. Systemic blood pressure measures 140/90 mm Hg or higher on at least two occasions a minimum of 1 to 2 weeks apart.
Intracerebral Haemorrhage. Clinical Context ICH accounts for up to 15% of first-time strokes and is associated with a 30-day mortality rate between 35%
Blood Pressure Lability During Cardiac Surgery Is Associated With Adverse Outcomes Solomon Aronson, Edwin G. Avery, Cornelius Dyke, Joseph Varon, Jerrold.
Selection of Antihypertensive Drug. BP ClassificationSystolic BP, mm Hg Diastolic BP, mm Hg Normal
Management of Hypertensive Emergencies. New paradigm in treatment of acute hypertension Acute vascular injury has chronic sequelae Prevention of exaggerated.
Systolic hypertension not an isolated problem Michael Weber, MD Professor of Medicine Associate Dean Downstate College of Medicine State University of.
Sofiya Lypovetska MD PhD Ternopil state medical university
Molly Adams, Pharm.D., BCPS Brad Wright, Pharm.D., BCPS
Blood Pressure Hypertension is a major risk factor for heart disease and stroke. As the first and fourth leading causes of death in the United States.
Severely Increased Blood Pressure In The ED: Treating The Mercury? Rick Blubaugh, D.O. Cornerstone Physician’s Management Group Skaggs Community Health.
Stroke and the ED Kurian Thomas, MD Department of Neurology.
Management of hypertensive urgencies & emergencies.
This lecture was conducted during the Nephrology Unit Grand Ground by a Sub-intern under Nephrology Division, Department of Medicine in King Saud University.
MODULE 3 CHAPTER 2D HYPERTENSION AND CVA The plan Introduction Primary prevention of stroke Management of hypertension during acute stoke Secondary.
Management of Hypertensive Emergencies
Evidence in the ED Byron Drumheller, MD Penn Emergency Medicine.
Complication during pregnancy and its nursing management: - Pregnancy induces hypertension. Clinical Aspect of Maternal and Child Nursing NUR 363 Lecture.
Management of severe hypertension.  For women with persistent chronic hypertension with SBP >160 or DBP >105, start antihypertensive therapy  Maintain.
Aim To determine the effects of a Coversyl- based blood pressure lowering regimen on the risk of recurrent stroke among patients with a history of stroke.
Treatment of Ischaemic Stroke The American Heart Association American Stroke Association Guidelines Stroke. 2007;38:
Edward C. Jauch, MD, MS FACEP 1 Research Horizons in the Acute Management of ICH.
Hypertension. Phone Call Why is patient in hospital? Is patient pregnant (preeclampsia)? How high is BP and what has it been previously?
Subarachnoid Hemorrhage Nina T. Gentile, MD Associate Professor Division of Emergency Medicine Temple University School of Medicine Philadelphia, PA.
Case 60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her whole body started.
Michelle Gardner RN NUR-224. OBJECTIVES  Define normal blood pressure and categories of abnormal pressure  Identify risk factors for hypertension 
VBWG OASIS-6 The Sixth Organization to Assess Strategies in Acute Ischemic Syndromes trial.
Blood pressure in acute stroke Presented by Ri 李俊豪.
Stroke Rami Unterman, M.D.. Objectives Define and differentiate the types of stroke Recognize the urgency involved in the evaluation and management of.
Optimal Blood Pressure Control in Intracerebral and Subarachnoid Hemorrhage Stephan A. Mayer, MD Assistant Professor of Neurology (in Neurological Surgery),
Adult Stroke 2010 AHA Guidelines for CPR and ECC
The impact of hyperacute blood pressure lowering on the early clinical outcome following intracerebral hemorrhage Ryo Itabashia, Kazunori Toyodaa,b, Masahiro.
Cerebral Vasospasm Saeed Fareghbal M.D QUMS Rajaei hospital Neurosurgery ward.
Hypertension In The Stroke Patient
Cedars-Sinai Medical Center and University of California Irvine
Hypertension JNC VIII Guidelines.
Blood Pressure and Age in Controlling Hypertension
Traditional parenteral antihypertensive treatment
Performance Improvement: Emergency Management in Acute Cerebrovascular Patients Current US Guidelines Lisa A. Shultz, MD Medical Director, Lourdes Stroke.
Approach to Hemorrhagic and Ischemic Strokes
Progress and Promise in RAAS Blockade
Strokes.
Newer parenteral antihypertensive treatment
HYPERTENSIVE CRISES Mini-Lecture.
Management of perioperative hypertension
HYPERTENSIVE CRISES.
Hypertensive Crises Diagnosis and Treatment
Table of Contents Why Do We Treat Hypertension? Recommendation 5
Update from education committee
Chapter 32 Assessment and Management of Patients With Hypertension
Improving Management of Acute HTN in Patients With Stroke
Hypertensive Crisis Halmat M. Jaafar (MSc. Clinical pharmacy)
Presentation transcript:

BP Control and Stroke Pro Calcium Blockers “Melee Mayer” Con Calcium Blockers “Power-Punch Pancioli”

Stephan A. “Melee” Mayer, MD

Calcium Channel Blockers for Stroke: PRO Stephan A. Mayer, MD Associate Professor of Neurology & Neurosurgery Columbia University Director, Neuro-ICU New York Presbyterian Hospital New York, NY

Outcome after Acute Ischemic Stroke by Admission Blood Pressure 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 – n = 18 < 120 n = n = n = n = n = 87 > 200 Post neurological outcome % Systolic BP on admission (mm Hg) C 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 – n = 18 < 120 n = n = n = n = n = 87 > 200 Early neurological deterioration % Systolic BP on admission (mm Hg) A 90 – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 – Post neurological outcome % Diastolic BP on admission (mm Hg) D n = 38 < 70 n = n = n = n = n = 102 > – 80 – 70 – 60 – 50 – 40 – 30 – 20 – 10 – 0 – n = 38 < 70 n = n = n = n = n = 102 > 110 Early neurological deterioration % Diastolic BP on admission (mm Hg) B Castillo J, et al. Stroke. 2004;35:520–526.

Management of Hypertension in Acute Ischemic Stroke: Patients Not Eligible for tPA SBP <220 mm Hg or DBP <120 mm Hg –No antihypertensive therapy SBP >220 mm Hg or DBP >120 mm Hg –Labetalol 20, 40, 60, 80 mg IVP –Nicardipine 5–15 mg/h Adams HP, et al. Stroke. 2003;34:1056–1083. SBP, systolic blood pressure; DBP, diastolic blood pressure.

Management of Hypertension in Acute Ischemic Stroke: Patients Eligible for tPA (Pre and Post) Adams HP, et al. Stroke. 2003;34:1056–1083. SBP <180 mm Hg and DBP <105 mm Hg –No antihypertensive therapy SBP >180 mm Hg or DBP >105 mm Hg –Labetalol 20, 40, 60, 80 mg IVP –Nicardipine 5 – 15 mg/h

Treatment of Hypertension in Acute ICH (1999) Recommendations Maintain MAP <130 mm Hg and SBP <180 mm Hg if history of hypertension If ICP monitored, keep CPP (MAP – ICP) >70 mm Hg CPP, cerebral perfusion pressure; MAP, mean arterial pressure; ICP, intracranial pressure. Broderick JP, et al. Stroke. 1999;30:905–915.

High or Low Admission SBP in ICH Patients Correlates with Increased Mortality < >220 n = 7n = 24n = 34n = 50n = 39N = 24n = † NC * N = 191. *P < vs SBP 141–160 mm Hg on admission. †P < 0.05 vs SBP 141–160 mm Hg on admission. NC, confidence interval not calculated due to <8 cases. 1 month12 months Mortality Rate (%) SBP (mm Hg) Adapted from: Vemmos KN, et al. J Intern Med. 2004;255:

Cerebral Autoregulation Is Central to Treatment of Hypertensive Crises normotensive chronic hypertensive Increasing risk of hypertensive encephalopathy Increasing risk of ischemia Patients with cerebral ischemia lose their ability to autoregulate vasoparalysis Cerebral Blood Flow Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214–227. MAP (mm Hg)

Specific Agents

Antihypertensive Agents Used in Hypertensive Crisis Clonidine Diazoxide Enalaprilat Esmolol Fenoldopam Hydralazine Labetalol Nicardipine Nifedipine Nitroglycerin Nitroprusside Phentolamine Trimethaphan

Antihypertensive Agents Used in Hypertensive Crisis Clonidine Diazoxide Enalaprilat Esmolol Fenoldopam Hydralazine Labetalol Nicardipine Nifedipine Nitroglycerin Nitroprusside Phentolamine Trimethaphan

Antihypertensive “Escalation” for Emergency Treatment of Hypertension Nitroprusside –Cerebral vasodilation may produce or aggravate increased ICP Nicardipine Labetalol or esmolol –May worsen bronchospasm –Causes bradycardia –May worsen heart failure Nitropaste Increasing Severity of Hypertension

Nitroprusside: NOT the Greatest BP Agent for Patients with Stroke Unstable dose-response relationship Directly increases ICP via cerebral vasodilation Toxicity with longer infusions (>72 hours)

Nicardipine vs Nitroprusside: Postoperative Hypertension Titration of Study Medications Halpern NA, et al. Crit Care Med. 1992;20:1637–1643. Time to Response (min) Number of Dose Changes Adverse Events Nicardipine (n = 71) 14.1 ± 11.5 ± 0.27% Nitroprusside (n = 68) 30 ± ± 1.418% P = 0.003P < 0.05 Mean ± SEM.

Nicardipine: Pharmacokinetics of IV Bolus Administration Adapted from Cheung AT, et al. Anesth Analg. 1999;89: Time after Drug Administration (h) Plasma Nicardipine Concentration (ng/mL) Group 1: 0.25 mg Group 2: 0.5 mg Group 3: 1.0 mg Group 4: 2.0 mg

Nicardipine vs Adrenergic Blockers Drug Nicardipine (Cardene ® IV) Esmolol (Brevibloc ® ) Labetalol AdministrationContinuous infusion* Bolus, continuous infusion Bolus, continuous infusion Onset + offsetRapid Slower Contractility0Decreased HRMinimal increaseDecreased SVRDecreased0 Cardiac outputIncreasedDecreased+/- Myocardial O 2 balance Positive ContraindicationsAdvanced aortic stenosis Bradycardia Heart block >1° CHF Bronchospasm COPD Bradycardia Heart block >1° CHF Bronchospasm COPD

Nicardipine Labetalol

The Evidence Base Randomized controlled trials comparing nicardipine and labetalol for BP control in ED-treated stroke patients HA HA HA!

Acute Intracerebral Hemorrhage Approximately 2 hours after onset of symptoms

“Soft Landing” in a Narrow Target Range :004:005:006:007:008:009:00 Time mm Hg 10 Nicardipine Infusion Dose (mg/h) 15 8 SBPMAPDBP Target SBP Target MAP Range

“Jagged” BP Profile with Intermittent IVP :004:005:006:007:008:009:00 Time mm Hg Labetalol 40 mg IVP SBPMAPDBP Target SBP Target MAP Range

Calcium Channel Blockers for Acute Stroke? Calcium channel blockers directly counteract the neurogenic pressor response Consider the IV infusion approach This is what we will do in the ICU EDs need to function as ICUs

Neurocritical Care Society

Arthur M. “Power-Punch” Pancioli, MD

Con: Blood Pressure Management in Stroke Calcium Channel Blockers Arthur M. Pancioli, MD, FACEP Associate Professor and Vice Chairman for Research Department of Emergency Medicine University of Cincinnati, College of Medicine Director of Emergency Cerebrovascular Research Greater Cincinnati/Northern Kentucky Stroke Team

Outline The Disease States Why Lower Blood Pressure? How to Do It?

The Disease States Acute ischemic stroke ICH Subarachnoid hemorrhage

Acute Ischemic Stroke

ICH

Early Hemorrhage Growth in Patients With ICH Growth at 1 hour on CT >33% Growth 33% Growth Change in NIH Stroke Scale 3.7 ± ± 2.6 Rankin Scale (4–6 weeks) 4.5 ± ± Day mortality 44%34% Brott T, et al. Stroke. 1997;28:1–5.

Aneurysmal Subarachnoid Hemorrhage

Outcome If You “Rebleed” After Sentinel Subarachnoid Hemorrhage Rebleeding significantly increased the odds of death (OR, 2.6; 95% CI, 1.1 to 6.3; P = 0.048) Reduced the odds of survival with good outcome (OR, 0.34; 95% CI, 0.13 to 0.92; P = 0.041) Beck J, et al. Stroke. 2006;37:2733–2737.

The Dance CPP = MAP – (ICP or CVP) When is MAP high enough? When is MAP too high?

My Experience with Calcium Channel Blockers

Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA, Volume 276, Number 16, October 23, 1996

Nimodipine: Subarachnoid Hemorrhage Nimotop ® (nimodipine) is indicated for the improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage from ruptured intracranial berry aneurysms regardless of their post-ictus neurological condition (ie, Hunt and Hess Grades I-V). DO NOT ADMINISTER NIMOTOP INTRAVENOUSLY OR BY OTHER PARENTERAL ROUTES. DEATHS AND SERIOUS, LIFE- THREATENING ADVERSE EVENTS HAVE OCCURRED WHEN THE CONTENTS OF NIMOTOP CAPSULES HAVE BEEN INJECTED PARENTERALLY. (See WARNINGS and DOSAGE AND ADMINISTRATION.)

Titratable Agents for Hypertensive Cerebrovascular Emergencies

What Do I Want? Predictability Speed Ease

Let’s Go Disease by Disease Acute Ischemic Stroke: SBP >220 mm Hg / DBP >120 mm Hg OR - when using tPA: SBP <185 mm Hg / DBP <110 mm Hg IF I MUST – Then I have a lot more experience with labetalol and it reliably does BOTH the things I want

Let’s Go Disease by Disease ICH: Keep MAP 70 mm Hg Subarachnoid Hemorrhage: Keep MAP 70 mm Hg General rule: keep SBP <160 mm Hg WHEN I CAN – I Like labetalol or esmolol; they do everything I want and I can choose how to do it

Pro Calcium Blockers “Melee Mayer”

Con Calcium Blockers “Power-Punch Pancioli”

My Memories of Your Therapy

By The Way If we haven’t said it yet: I am NOT a hydralazine fan –It has defined unpredictable in my world

By the Way, Nitroprusside and ICP Changes in Intracranial Pressure with Nitroprusside Therapy

Time for a CONFESSION