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Blood Pressure Management in Acute Stroke: Comparison of Current Guidelines with Prescribing Patterns

Published online by Cambridge University Press:  14 September 2018

Salmann Kanji
Affiliation:
Department of Pharmacy, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
Céline Corman
Affiliation:
Department of Pharmacy, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
Andre G. Douen
Affiliation:
Division of Neurology, The Ottawa Hospital - General Campus, University of Ottawa, Ottawa, ON Canada
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Abstract:

Objective:

Current recommendations for treating elevated blood pressure (BP) in the acute stroke are based largely on expert opinion and vary with regard to treatment thresholds and choice of antihypertensive agents. In this study we investigate the influence of these recommendations by comparing the management of hypertension in acute stroke at a tertiary care hospital with current guidelines.

Method:

Retrospective chart review of patients admitted with acute stroke at The Ottawa Hospital-General Campus over six consecutive months. The use of antihypertensive medications (type, dose, routes of administration, BP recordings) in the first seven days after admission was noted.

Results:

Transdermal nitroglycerin paste was the most commonly used antihypertensive agent. In contrast to the 15% reduction in BP over 24 hours recommended for lowering BP in hypertensive patients with ischemic stroke, nitroglycerin caused a >15% reduction of BPover the first 24 hours on 60% of the occasions used. Furthermore, despite concerns about sublingual nifedipine, this was the second most commonly prescribed agent. Surprisingly, the mean time to first BP measurement following initiation of antihypertensive therapy was 117 ± 43 minutes in ischemic stroke and 88 ± 89 minutes in hemorrhagic strokes.

Conclusions:

The current guidelines for management of acute poststroke hypertension appear to have little influence on prescribing patterns, leading to considerable variations in practice. Such variations, likely due to uncertainty caused by lack of evidence from randomised controlled trials, are intolerable as patients maybe submitted to nonstandardised, potentially harmful care such as inappropriate choice of antihypertensives and inadequate BP monitoring as observed in this study.

Résumé:

Résumé: Objectif:

Les recommandations en vigueur pour le traitement de l’hypertension artérielle (HTA) dans l’accident vasculaire cérébral aigu (AVCA) sont basées en grande partie sur l’opinion d’experts et varient quant aux niveaux où un traitement est indiqué et au choix d’agents antihypertenseurs. Dans cette étude, nous évaluons l’influence de ces recommandations sur la pratique en comparant la prise en charge de l’hypertension dans l’AVCA dans un hôpital de soins tertiaires et les lignes directrices en vigueur.

Méthode:

Il s’agit d’une revue de dossiers de patients présentant un AVCA admis à l’Hôpital Général d’Ottawa sur une période de six mois. L’utilisation de médicaments antihypertenseurs (type, dose, voie d’administration, lectures de tension artérielle (TA)) pendant les sept premiers jours après l’admission ont été relevés.

Résultats:

La nitroglycérine administrée par voie transdermique était l’agent antihypertenseur le plus souvent utilisé. Alors que la baisse de la TA recommandée chez les patients hypertendus présentant un AVCAischémique est de 15% sur 24 heures, la nitroglycérine a causé une baisse de plus de 15% de la TAsur 24 heures dans 60% des cas où elle a été utilisée. De plus, malgré les préoccupations quant à l’utilisation de la nifédipine sublinguale, c’était le deuxième agent le plus souvent prescrit. Il était étonnant de constater que l’intervalle moyen entre la première lecture de TA suivant le début de la médication antihypertensive était de 117 ± 43 minutes dans l’AVC ischémique et de 88 ± 89 minutes dans l’AVC hémorragique.

Conclusions:

Les lignes directrices actuelles pour la prise en charge de l’hypertension post AVCA semblent avoir peu d’influence sur le mode de prescription, ce qui entraîne des variations considérables dans la pratique. De telles variations, probablement dues à l’incertitude causée par le manque de données provenant d’études contrôlées randomisées, sont intolérables parce que les patients peuvent être soumis à des soins non standardisés potentiellement nocifs tels des choix inappropriés d’agents antihypertenseurs et une surveillance inadéquate de la TAcomme on l’a observé dans cette étude.

Type
Original Article
Copyright
Copyright © Canadian Neurological Sciences Federation 2002

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