Systolic Blood Pressure Variability When Transitioning From Intravenous to Enteral Antihypertensive Agents in Patients With Hemorrhagic Strokes

 

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 from their strokes.

• blood pressure management (48 posts to June 2017)

5 years and still incompetent leadership in stroke.

Systolic Blood Pressure Variability When Transitioning From Intravenous to Enteral Antihypertensive Agents in Patients With Hemorrhagic Strokes

Abdulrahman I. Alshaya^1,2,3*, Meshari Alghamdi^1,2,3, Sumaya N. Almohareb^1,2,3, Omar A. Alshaya^1,2,3, Mohammed Aldhaeefi^1,2,3,4, Abdullah F. Alharthi² and Sulaiman Almohaish^5,6

• ¹Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
• ²King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
• ³King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
• ⁴Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, United States
• ⁵Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, United States
• ⁶Pharmacy Practice Department, College of Clinical Pharmacy, King Faisal University, Hofuf, Saudi Arabia

Background/Objective: Systolic blood pressure variability (SBPV) in patients with intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is associated with an increased risk of acute kidney injury (AKI) and mortality. SBPV is a strong predictor of poor functional outcomes in patients with ICH. Intravenous (IV) antihypertensive agents are commonly used to achieve sustained target blood pressure goals; however, this is not a feasible long-term option. The transition from IV to enteral antihypertensives is not yet well established in patients with ICH and SAH. This study aimed to assess the effect of the number of antihypertensive agents and overlap time during the transition period from IV to enteral route on SBPV in patients with ICH and SAH.

Methods: This retrospective single-center study was conducted at a tertiary teaching hospital in Riyadh, Saudi Arabia. Data were extracted from electronic medical records after obtaining Institutional Review Board approval. Patients were included if they were >18 years old, admitted with spontaneous ICH or SAH, and received continuous infusion antihypertensives prior to transitioning to the enteral route. The major outcome was the effect of the number of antihypertensive agents and overlap time on SBPV during the transition process. Minor outcomes included the effect of the number of antihypertensive agents and overlap time on heart rate variability and the incidence of AKI on day 7.

Results: After the screening, we included 102 patients. Based on our regression model, the number of enteral antihypertensive agents upon transitioning from IV to enteral antihypertensive therapy had no effect on SBPV in the intensive care unit (ICU) among our patients (p-value = 0.274). However, the prolonged overlap was associated with reduced SBPV in the ICU (p-value = 0.012). No differences were observed between the groups in heart rate variation or AKI rate.

Conclusions: In patients with ICH and SAH, prolonged overlap of enteral antihypertensive agents to overlap with intravenous antihypertensive therapy may result in lower SBPV. This finding needs to be confirmed on a larger scale with more robust study designs for patients with ICH and SAH.

Introduction

Hemorrhagic stroke represents 10−20% of stroke cases annually (1). It is considered a neurological emergency that requires complete and comprehensive management as it carries a high risk of mortality and morbidity (2, 3). Acute hypertension is a common finding in patients with intracranial hemorrhage (ICH) or subarachnoid hemorrhage (SAH) (4). High blood pressure is an independent cause and risk factor for hemorrhagic stroke, and significant systolic blood pressure variability (SBPV) in these patients may lead to poor functional status and mortality (5–8). The exact mechanism and etiology of this variability are still not fully understood. However, it could be related to either an increase in the sympathetic system activity, reduced baroreceptor reflexes, increased arterial stiffness, humanteral, rheological, environmental, behavioral, and emotional factors, age, activity/sleep, and medication-related issues (9, 10). The optimal management of blood pressure (BP) during the acute stages of hemorrhagic stroke remains controversial. Available data from large randomized trials did not provide consistent recommendations regarding target BP and how to achieve it. The American Heart Association guidelines for ICH and SAH recommend targeting a systolic BP goal of <140–160 mmHg during the acute phase (11, 12).

The magnitude of safe BP reduction from baseline BP upon admission with ICH or SAH has not yet been established. BP fluctuation or variability in ICH or SAH has been discussed in multiple recent studies that examined SBPV during the first 24 h in patients with ICH or SAH (13, 14). They found an association between SBPV and unfavorable functional outcomes. The post-hoc analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 (INTERACT2), Field Administration of Stroke Therapy-Magnesium (FAST-MAG), and Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trials found that SBPV is a strong predictor of poor outcomes in patients with ICH and increases mortality risk with worse neurological outcomes (13–15). Regarding patients with SAH, current evidence provides similar results regarding SBPV and poor outcomes, as in patients with ICH (8, 16).

Intravenous (IV) antihypertensive agents, such as labetalol and nicardipine IV continuous infusion, are commonly used to achieve sustained target BP goals in the acute phase of hemorrhagic stroke (17, 18). Nonetheless, this is not a feasible, long-term option. The transition process of antihypertensive agents from IV to an enteral route is not yet well established in patients with ICH or SAH. Thus, this study aimed to investigate the SBPV of antihypertensive agents during the transition period from IV to enteral route in patients with ICH and SAH.

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