1) Welcome to a tweetorial on #hypertension mgt in #stroke–such an important #EmergencyMedicine and #Neurology issue. Accredited for 0.50h by @academiccme: #physicians, #nurses, #pharmacists. I am @EvieMarcolini . . . pic.twitter.com/zj0zy7GH9D
— cardio-met (@cardiomet_CE) June 8, 2021
2) First, a case: a 72 y/o male is brought to ED with R-sided hemiplegia, slurred speech, and R facial droop. Last known normal time was 1.5h prior to arrival. Current meds include lisinopril, atorvastatin, warfarin.
— cardio-met (@cardiomet_CE) June 8, 2021
4) The answer is d, since we have not established whether this is an ischemic or hemorrhagic stroke. The BP goals for ischemic and hemorrhagic stroke are very different. In the case of spontaneous intracerebral hemorrhage, the BP goals revolve around two components . . .
— cardio-met (@cardiomet_CE) June 8, 2021
6) . . . will have physiology that is accustomed to a higher pressure, therefore the established optimal goal is <180, a target that hasn’t changed since at least 1993 (Neurology. 1993; 43: 461–467) . . . think of perfusing the kidneys here.
— cardio-met (@cardiomet_CE) June 8, 2021
8) . . . as well as the ATACH1 trial (N Engl J Med 2016; 375:1033-1043) all showed that targeting BP to <140 was feasible and safe. These were limited small trials, and the world awaited ATACH2, already “knowing” the answer.
— cardio-met (@cardiomet_CE) June 8, 2021
10) ATACH-2 utilized nicardipine and trial limitations included lack of knowledge of the patients’ previous average blood pressure and the fact that most patients’ systolic BP ranged between 140-160 in the study, thus not adequately stratifying them.
— cardio-met (@cardiomet_CE) June 8, 2021
12) A non-contrast CT is obtained for this patient, and reveals no hemorrhage – but his clinical exam has not changed. He is now 2 hours out from his last known normal exam and labs show an INR of 1.5. Now what is the optimal blood pressure goal?
— cardio-met (@cardiomet_CE) June 8, 2021
14) Welcome back to our accredited tweetorial on acute BP management in stroke! I am @EvieMarcolini. Shout outs to @MicieliA_MD @LaurenSanders81 @emlitofnote @amalmattu @First10EM @GastonFRodrigu1 @razmik_dr @nsanar @AliNsairMD @ClaudeHemphill @timeisbrain @HarmanSGill @yaleem2
— cardio-met (@cardiomet_CE) June 9, 2021
16) You absolutely can administer thrombolysis, but must lower the blood pressure first. What is your agent of choice?
— cardio-met (@cardiomet_CE) June 9, 2021
18) Nitroprusside is an option, but less favored in the setting of acute ischemic stroke as it is thought to have adverse effects on cerebral autoregulation and intracranial pressure and may “bottom out” the BP, which is hazardous.
— cardio-met (@cardiomet_CE) June 9, 2021
20) . . . but what is the lower limit for optimal outcome? Does it matter? In this scenario, we are balancing the desire for a higher BP to perfuse the injured penumbral tissue surrounding the core infarct with the risk of intracerebral hemorrhage from reperfusion.
— cardio-met (@cardiomet_CE) June 9, 2021
22) . . . that an optimal blood pressure after thrombolysis was systolic 141-150 mm Hg. The incidence of symptomatic hemorrhage decreased with BP lower than 141 systolic, but mortality and functional independence were optimal at systolic 141-150.
— cardio-met (@cardiomet_CE) June 9, 2021
24) Investigators asked whether targeting a lower BP than the guideline-indicated <180 systolic would improve outcome for patients receiving systemic thrombolysis. Would a target of 130-140 improve outcome by reducing the risk of ICH?
— cardio-met (@cardiomet_CE) June 9, 2021
26) While this study showed safety in targeting lower blood pressure, the gains of reducing the rate of hemorrhage may have been offset by lower cerebral perfusion and resulting ischemia.
— cardio-met (@cardiomet_CE) June 9, 2021
28) . . . but it may be offset by an increase in cerebral edema. Stay tuned for more on that. For the time being, you decide to target <180, per guidelines, and he is sent back for CT angiography, which shows a large vessel occlusion (LVO) in the left middle cerebral artery.
— cardio-met (@cardiomet_CE) June 9, 2021
30) Mark your best answer and return tomorrow for the answer and a link to your FREE CE/#CME! @AliRaja_MD @UMEMresidency @OchsnerEM @GrigoryMD @BridgingICUGap @NeuroIntact @icem2020 @TSYounMD @StricklerSammie @jem_journal @jacksonmiamiEM @EBmedicine @ThinkingCC @ResusMed
— cardio-met (@cardiomet_CE) June 9, 2021
32) Most trials have adhered to the recommendations consistent with patients receiving systemic thrombolysis, but the ESCAPE trial (NEJM 2015;372:1019-30) maintained SBP <150 prior to reperfusion and targeting a normal blood pressure afterward.
— cardio-met (@cardiomet_CE) June 10, 2021
34) In these cases, allowing the blood pressure to remain high in order to maximize collateral circulation and perfusion to the injured penumbra is recommended. If the blood pressure is >220/120 it’s uncertain whether there is any benefit . . .
— cardio-met (@cardiomet_CE) June 10, 2021
36) Care should be taken to be judicious, targeting 15% BP reduction in the first 24 hours. One could use clevidipine or nicardipine; a non-randomized comparison between the two in stroke or ICH (J Intens Care Med 2019;34:990-995), there was . . .
— cardio-met (@cardiomet_CE) June 10, 2021
38) . . . favoring clevidipine in this patient population, with most patients achieving this goal in less than 1 h. The terminal half-life of clevidipine is also markedly shorter, meaning that it should be an option in these neuro patients needing fine control of BP.
— cardio-met (@cardiomet_CE) June 10, 2021
40) The awesome human brain is always working to optimize its own outcome. With autoregulation via vasoconstriction and vasodilation, it maintains pressure keeping the sensitive neurons in a steady state for optimal performance. pic.twitter.com/BmXdy4YIEO
— cardio-met (@cardiomet_CE) June 10, 2021
42) . . . tend to present with a lower SBP, perhaps because their collaterals are at work. These patients also tend to have a better chance of recanalization with smaller ultimate volume of infarcted tissue.
— cardio-met (@cardiomet_CE) June 10, 2021
44) That’s it! You made it! Free CE/#CME! Now go to https://t.co/ByGBLGTGAh and claim your credit! I am @EvieMarcolini. Follow @cardiomet_CE for more tweetorials, and visit https://t.co/U6Mo1oSwIh for unrolled programs where the credit opportunity is still active! #FOAMed
— cardio-met (@cardiomet_CE) June 10, 2021