How is hypertension controlled in patients receiving rt-PA for the acute management of stroke?

Updated: Sep 08, 2017
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Answer

For patients who will be receiving rt-PA, systolic blood pressure greater than 185 mm Hg and diastolic blood pressure greater than 110 mm Hg require intervention. Monitoring and control of blood pressure during and after thrombolytic administration are vital, because uncontrolled hypertension is associated with hemorrhagic complication. [28]

The initial drug of choice, labetalol (10-20 mg IV for 1-2 min), may be repeated (maximum dose 300 mg). One to 2 inches of transdermal nitropaste (see nitroglycerin topical) may also be used. As an alternative to these choices, nicardipine infusion at 5 mg/h, titrated up to a maximum dose of 15 mg/h, can be used. [19]

Monitoring of blood pressure is crucial; for the first 2 hours, blood pressure should be checked every 15 minutes, then every 30 minutes for 6 hours, and finally, every hour for 16 hours. The goal of therapy should be to reduce blood pressure by 15-25% in the first day, with continued blood pressure control during hospitalization.

For patients with systolic blood pressure of 185-230 mm Hg or diastolic blood pressure of 110-120 mm Hg, labetalol is given at a dose of 10-20 mg IV over 1-2 minutes; the dose may be repeated every 10-20 minutes, up to 300 mg total, or an infusion rate of up to 2-8 mg/min may be used. [1]

For systolic blood pressure of greater than 230 mm Hg or diastolic blood pressure of 121-140 mm Hg, labetalol at the above doses can be considered. However, nicardipine infusion administered at a rate of 5 mg/h, to a maximum of 15 mg/h, might be a better first choice. For difficult-to-control blood pressure, sodium nitroprusside can be considered. [1]

The use of sublingual nifedipine to lower blood pressure in the ED is discouraged, since extreme hypotension may result. Trials of nimodipine, initially thought to be beneficial given its vasodilatory effect as a calcium-channel blocker, have failed to demonstrate any beneficial outcome in comparison with placebo. [18]

Consensus agreement is that these blood pressure guidelines should be maintained in the face of other interventions to restore perfusion, such as intra-arterial thrombolysis. [1]

Table 3. Blood Pressure Management in Patients With Stroke* (Open Table in a new window)

 

Blood Pressure

Treatment

Candidates for fibrinolysis

Pretreatment:

SBP >185 or DBP >110 mm Hg

Labetalol 10-20 mg IVP repeated every 10-20 minutes

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h or

Enalapril 1.25 mg IVP

 

Posttreatment:

DBP >140 mm Hg

SBP >230 mm Hg or

DBP 121-140 mm Hg

SBP 180-230 mm Hg or DBP 105-120 mm Hg

Sodium nitroprusside (0.5 mcg/kg/min)

Labetalol 10-20 mg IVP and consider labetalol infusion at 1-2 mg/min or nicardipine 5 mg/h IV infusion and titrate

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h or

Labetalol 10 mg IVP, may repeat and double every 10 min up to maximum dose of 300 mg

Noncandidates for fibrinolysis

DBP >140 mm Hg

SBP >220 or

DBP 121-140 mm Hg or

MAP >130 mm Hg

SBP < 220 mm Hg or

DBP 105-120 mm Hg or

MAP < 130 mm Hg

Sodium nitroprusside 0.5 mcg/kg/min; may reduce approximately 10-20%

Labetalol 10-20 mg IVP over 1-2 min; may repeat and double every 10 min up to maximum dose of 150 mg or nicardipine 5 mg/h IV infusion and titrate

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h

Antihypertensive therapy indicated only if acute myocardial infarction, aortic dissection, severe CHF, or hypertensive encephalopathy present

*Adapted from 2005 Advanced Cardiac Life Support (ACLS) guidelines and 2007 American Stroke Association Scientific Statement

Abbreviations: SBP - systolic blood pressure; DBP - diastolic blood pressure; IVP - IV push; MAP - mean arterial pressure


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