Nicardipine Offers Fast Track to Target Blood Pressure During Neurologic Emergencies

Nancy A. Melville

October 01, 2010

October 1, 2010 (Las Vegas, Nevada) — The calcium-channel blocker nicardipine (Cardene, EKR Therapeutics) can rapidly achieve target blood pressure in patients in the emergency department with neurologic emergencies, according to research presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

The observational study of 99 patients with neurologic emergencies found that those who were given nicardipine achieved target blood pressure within 12 hours more frequently than those given other antihypertensives. The median time to target blood pressure was 38 minutes, compared with an average of 155 minutes for patients who did not receive nicardipine.

"The bottom line is that we all have a great interest in what to do with these very hypertensive neurological patients because we recognize that there will probably be a day when we'll find that, if we appropriately modulate blood pressure in these patients, we can probably affect outcome," said Arthur Pancioli, MD, associate professor and vice chair at the University of Cincinnati Department of Emergency Medicine in Ohio, and a coauthor on the study.

"We wanted to take a very aggressive look at exactly what happens to blood pressure based on the interventions used in the emergency department," Dr. Pancioli explained.

The study involved patients at 1 academic and 2 community emergency departments. Diagnoses included intracerebral hemorrhage (n = 36), ischemic stroke (n = 34). and hypertensive emergency (n = 10).

Nine patients received only nicardipine, 33 received nicardipine plus another antihypertensive, and 57 received only other antihypertensives.

Dr. Pancioli reported that 38% of patients who received nicardipine plus other antihypertensives became hypotensive, compared with 19% of patients who received antihypertensives other than nicardipine (P = .038). In addition, 22% of those who received nicardipine alone became hypotensive, compared with 19% of those who received other antihypertensives, but not nicardipine (P = 1.00).

"Patients who got nicardipine plus other drugs did get hypotensive a little more often than those who got nicardipine alone," he said.

Target blood pressure was achieved within 12 hours in 93% of patients receiving nicardipine, compared with 75% of those receiving other antihypertensives (P < .05). Target blood pressure was defined, according to American Heart Association guidelines, as a 20% reduction in systolic blood pressure recorded immediately prior to treatment.

Hypotension was defined as systolic blood pressure dropping below 100 mm Hg or as a decrease of more than 40% in the 12 hours after the initiation of antihypertensives in the emergency department.

Dr. Pancioli noted that the findings suggest the value of nicardipine as an important tool with neurologic emergencies, and underscore the need to use caution with the treatment.

"The number of patients was relatively small, but the study is very robust in terms of data collection. The bottom line is that nicardipine performs very well on its own, but when combined with other drugs, it may give a little hypotension," he cautioned. "I would be very careful when you start mixing agents, because you never know quite what you're going to get with that subsequent second agent."

Limitations of the study include the fact that it was not randomized and was observational, Dr. Pancioli noted. "Ultimately, we hope to take some of these data and look at the blood pressure curves, but in general, from an observational standpoint, this was a fairly positive trial looking at how nicardipine works."

Baker Fore, MD, a preventive medicine specialist from the Interdisciplinary Pain Center in Ardmore, Oklahoma, said the findings support the need to always look at the bigger picture when considering an appropriate therapy in an emergency situation.

"A much stronger agent such as nicardipine will get you results faster, but there is less of a margin for error and the decision may cause stronger side effects," he said. "Knowing this means you have to consider all the other factors regarding the individual patient before you reach for the big gun in any situation."

The study received support from EKR Therapeutics. Dr. Pancioli and Dr. Fore have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 240. Presented September 28, 2010.