Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

 

So we still have NO FUCKING CLUE what a blood pressure management protocol is. Hope you don't mind dying because of the cesspools of incompetence of the complete stroke medical world.  Unless YOU hold your stroke hospital's feet to the fire you are allowing your children and grandchildren to die or become disabled.

And with no measurement of 100% recovery they are not even trying to solve stroke.

Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

 

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Sara Mazzucco, Linxin Li, Iain J McGurgan, ...

First Published January 7, 2022 Research Article 

https://doi.org/10.1177/17474930211068655

Article information

Abstract

Background:

Effects of early blood pressure (BP) lowering on cerebral perfusion in patients with moderate/severe occlusive carotid disease after transient ischemic attack (TIA) and non-disabling stroke are uncertain.

Aims:

We aimed to evaluate the changes in transcranial Doppler (TCD) indices in patients undergoing blood pressure lowering soon after TIA/non-disabling stroke.

Methods:

Consecutive eligible patients (1 November 2011 to 30 October 2018) attending a rapid-access clinic with TIA/non-disabling stroke underwent telemetric home blood pressure monitoring (HBPM) for 1 month and middle cerebral artery velocities measurements ipsilateral to carotid stenosis on TCD ultrasound in the acute setting and at 1 month. Hypertensive patients (HBPM ⩾ 135/85) underwent intensive BP-lowering guided by HBPM unless they had bilateral severe occlusive disease (⩾ 70%). Changes in BP and TCD parameters were compared in patients with extracranial moderate/severe carotid stenosis (between 50% and occlusion) versus those with no or mild (< 50%) stenosis.

Results:

Of 764 patients with repeated TCD measures, 42 had moderate/severe extracranial carotid stenosis without bilateral severe occlusive disease. HBPM was reduced from baseline to 1 month in hypertensive patients both with versus without moderate/severe carotid stenosis (−12.44/15.99 vs −13.2/12.2 mmHg, respectively, p-difference = 0.82), and changes in TCD velocities (4.69/14.94 vs 2.69/13.86 cm/s, respectively, p-difference = 0.52 for peak systolic velocity and 0.33/7.06 vs 1.75/6.84 cm/s, p-difference = 0.34 for end-diastolic velocity) were also similar, with no evidence of greater hemodynamic compromise in patients with stenosis/occlusion.

Conclusion:

There was no evidence of worsening of TCD hemodynamic indices in patients with moderate/severe occlusive carotid disease treated with BP-lowering soon after TIA/non-disabling stroke, suggesting that antihypertensive treatment in this group of patients is safe in the acute setting of TIA clinics.

Keywords

TIA, stroke, blood pressure, transcranial Doppler, carotid stenosis

Introduction

Blood pressure (BP) lowering after stroke/ transient ischemic attack (TIA) reduces risk of recurrence,^1,2 but some uncertainty remains around early initiation of antihypertensives in patients with carotid occlusive disease.³ There is no benefit, and even possible harm, from early BP-lowering in major acute stroke,⁴ particularly in the subset of patients with moderate/severe carotid stenosis,⁵ but there are few data on effects on cerebral perfusion in TIA and non-disabling stroke patients with carotid stenosis. One study showed no evidence of worsening cerebral perfusion, but numbers were small, patients were enrolled in the post-acute phase and data on perfusion ipsilateral to the arterial stenosis were not provided separately.³ In the PROGRESS trial of BP-lowering after stroke/TIA, benefit was seen in patients with large-artery stroke subtype,⁶ but few patients had evidence of carotid stenosis and randomized treatment was delayed until at least 6 weeks after the event.

Uncertainty around timing of antihypertensive treatment initiation and BP targets in TIA/non-disabling stroke patients with carotid stenosis might undermine clinicians’ confidence in early BP-lowering. Failing to prescribe antihypertensive treatment in the acute setting after TIA/non-disabling stroke is a missed opportunity for secondary prevention, as in-hospital prescription is known to be the strongest predictor of long-term adherence.^7–9 In the randomized trials of endarterectomy in patients with recently symptomatic carotid stenosis, we showed previously that risk of recurrent stroke in the no-surgery group increased with BP level in all but the subgroup with bilateral severe (⩾ 70%) stenosis/occlusion, in which the association was reversed, suggesting that intensive BP-lowering should be avoided in this group, whereas the association remained positive in those with only unilateral ⩾ 70% stenosis.¹⁰ We, therefore, tested the hypothesis that early BP-lowering would not decrease transcranial Doppler (TCD) blood flow velocities in consecutive patients with recent TIA/non-disabling stroke and ⩾ 50% extracranial carotid stenosis (without bilateral ⩾ 70% stenosis/occlusion) in a population-based cohort attending a rapid-access clinic, and compared results in patients with no significant carotid stenosis.

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