Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Patients With Stroke

2017 ◽  
Vol 34 (11-12) ◽  
pp. 990-995 ◽  
Author(s):  
Teresa A. Allison ◽  
Stephanie Bowman ◽  
Brian Gulbis ◽  
Heather Hartman ◽  
Sara Schepcoff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Reduction ◽  
Group Versus ◽  
Pressure Control ◽  
Care Needs ◽  
Observational Cohort ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Time Standard ◽  
Mean Time

Objective: The aim of this study was to determine whether clevidipine (CLEV) achieved faster blood pressure control compared to nicardipine (NIC) in patients presenting with either an acute ischemic stroke (AIS) or a spontaneous intracerebral hemorrhage (ICH). Methods: This was a retrospective, observational, cohort study conducted in patients with AIS or ICH admitted to the emergency department of a Comprehensive Stroke Center from November 2011 to June 2013 who received CLEV or NIC continuous infusion for acute blood pressure management. Results: The study included 210 patients: 70 in the CLEV group and 140 in the NIC group. There was no difference in mean time (standard deviation [SD]) from initiation of the infusion to goal systolic blood pressure (SBP), CLEV: 50 (83) minutes versus NIC: 74 (103) minutes, P = .101. Comparison of the 2 agents within diagnosis showed no difference. Hypotension developed in 5 (7.1%) CLEV patients versus 14 (10%) NIC patients ( P = .003). There was no difference in the percentage change at 2 hours; CLEV: −20% (16%) versus NIC: −16% (16%), P = .058. Mean (SD) time to alteplase administration from admission was 56 (22) minutes in the CLEV group versus 59 (25) minutes in the NIC group ( P = .684). Conclusions: There was no difference in the mean time from initiation of the infusion to the SBP goal between agents or in the secondary outcomes. Due to the lack of differences observed, each agent should be considered based on the patient care needs of the institution.

Abstract TMP56: Prediction of Primary Stroke: A Secondary Analysis of the SPRINT Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Adam H de Havenon ◽  
Eric Goldstein ◽  
Stephanie Lyden ◽  
Jennifer Majersik
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Blood Pressure Control ◽  
Primary Outcome ◽  
Disease Risk ◽  
Cardiovascular Disease Risk ◽  
Blood Pressure Reduction ◽  
Pressure Control ◽  
Significant Difference ◽  
History Of

Background: The Systolic Blood Pressure Intervention Trial enrolled patients aged 50 or older with at least one cardiovascular disease risk factor, but free of prior symptomatic stroke. Patients were assigned to two blood pressure reduction goals (<140 versus 120 mm Hg). There was not a significant difference in the rate of stroke, making this an ideal cohort to refine risk prediction of primary stroke, which is understudied in patients with adequate blood pressure control and a rigorously adjudicated outcome of stroke. Methods: The primary outcome is ischemic stroke. We fit Cox models to the primary outcome and evaluated all baseline demographic variables to determine which would be most predictive of stroke, which we then used to create a prediction score. Results: We included 9,361 patients with a mean (SD) age of 67.9 (9.4) years and 171 (1.8%) patients met the primary outcome of stroke. For our prediction model, we gave one point each for history of TIA, atrial fibrillation, congestive heart failure, or diabetes. Patients with 2 or more points were collapsed, making three possible scores of 0, 1, and 2, which had rates of stroke of 1.5% (117/8042), 3.2% (30/933), and 6.2% (24/386) (p<0.001). Compared to a score of 0, the hazard ratios for stroke of score 1 and 2 were 2.3 (95% CI, 1.6-3.5) and 4.6 (95% CI, 2.9-7.1) (both p<0.001) (Figure 1). Conclusion: A simple scoring system can improve prediction of ischemic stroke from 1.8% to 6.2% in patients with no prior history of stroke and excellent blood pressure control. This information could be used to improve patient selection for clinical trials or for identifying patients for more aggressive primary prevention strategies.

scholarly journals Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

2018 ◽  
Vol 10 (1) ◽  
pp. 57-62 ◽  
Author(s):  
Tapan Mehta ◽  
Sara Strauss ◽  
Dawn Beland ◽  
Gilbert Fortunato ◽  
Ilene Staff ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Medical Education ◽  
Acute Stroke ◽  
Simulation Training ◽  
Stroke Registry ◽  
Practice Experience ◽  
Intravenous Tissue Plasminogen Activator ◽  
Simulation Based ◽  
Comprehensive Stroke Center ◽  
Stroke Center

ABSTRACT Background  Literature on the effectiveness of simulation-based medical education programs for caring for acute ischemic stroke (AIS) patients is limited. Objective  To improve coordination and door-to-needle (DTN) time for AIS care, we implemented a stroke simulation training program for neurology residents and nursing staff in a comprehensive stroke center. Methods  Acute stroke simulation training was implemented for first-year neurology residents in July 2011. Simulations were standardized using trained live actors, who portrayed stroke vignettes in the presence of a board-certified vascular neurologist. A debriefing of each resident's performance followed the training. The hospital stroke registry was also used for retrospective analysis. The study population was defined as all patients treated with intravenous tissue plasminogen activator for AIS between October 2008 and September 2014. Results  We identified 448 patients meeting inclusion criteria. Simulation training independently predicted reduction in DTN time by 9.64 minutes (95% confidence interval [CI] –15.28 to –4.01, P = .001) after controlling for age, night/day shift, work week versus weekend, and blood pressure at presentation (&gt; 185/110). Systolic blood pressure higher than 185 was associated with a 14.28-minute increase in DTN time (95% CI 3.36–25.19, P = .011). Other covariates were not associated with any significant change in DTN time. Conclusions  Integration of simulation based-medical education for AIS was associated with a 9.64-minute reduction in DTN time.

scholarly journals Long-term benefit of renal denervation on blood pressure control in a patient with hemorrhagic stroke

2019 ◽  
Vol 7 ◽  
pp. 2050313X1987097
Author(s):  
Francesco Versaci ◽  
Giuseppe Andò ◽  
Marcello Chiocchi ◽  
Francesco Romeo
Keyword(s):  
Blood Pressure ◽  
Renal Denervation ◽  
Hemorrhagic Stroke ◽  
Blood Pressure Reduction ◽  
Pressure Control ◽  
Refractory Hypertension ◽  
Sustained Efficacy ◽  
Term Benefit

A 49-year-old man with malignant hypertension had been admitted with hemorrhagic stroke. Refractory hypertension had been observed during hospitalization and the decision had been made to perform renal denervation. A significant blood pressure reduction was obtained immediately after renal denervation and persists at 2-year follow-up. This case demonstrates the long-term sustained efficacy of renal denervation performed in the acute phase of hemorrhagic stroke. In addition, it supports the notion that renal denervation–induced normalization of blood pressure may contribute to better outcomes in a challenging setting such as intracranial bleeding.

scholarly journals Blood pressure reduction and RAAS inhibition in diabetic kidney disease: therapeutic potentials and limitations

2020 ◽  
Vol 33 (5) ◽  
pp. 949-963
Author(s):  
Giovanna Leoncini ◽  
Francesca Viazzi ◽  
Salvatore De Cosmo ◽  
Giuseppina Russo ◽  
Paola Fioretto ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Kidney Disease ◽  
Blood Pressure Control ◽  
Therapeutic Approach ◽  
Diabetic Kidney Disease ◽  
Blood Pressure Reduction ◽  
Pressure Control ◽  
Renal Outcome ◽  
Renal Protection ◽  
Diabetic Kidney

Abstract Diabetic kidney disease (DKD) affects approximately one-third of patients with diabetes and taking into consideration the high cardiovascular risk burden associated to this condition a multifactorial therapeutic approach is traditionally recommended, in which glucose and blood pressure control play a central role. The inhibition of renin–angiotensin–aldosterone RAAS system represent traditionally the cornerstone of DKD. Clinical outcome trials have demonstrated clinical significant benefit in slowing nephropathy progression mainly in the presence of albuminuria. Thus, international guidelines mandate their use in such patients. Given the central role of RAAS activity in the pathogenesis and progression of renal and cardiovascular damage, a more profound inhibition of the system by the use of multiple agents has been proposed in the past, especially in the presence of proteinuria, however clinical trials have failed to confirm the usefulness of this therapeutic approach. Furthermore, whether strict blood pressure control and pharmacologic RAAS inhibition entails a favorable renal outcome in non-albuminuric patients is at present unclear. This aspect is becoming an important issue in the management of DKD since nonalbuminuric DKD is currently the prevailing presenting phenotype. For these reasons it would be advisable that blood pressure management should be tailored in each subject on the basis of the renal phenotype as well as related comorbidities. This article reviews the current literature and discusses potentials and limitation of targeting the RAAS in order to provide the greatest renal protection in DKD.

scholarly journals The association between blood pressure control and Coronavirus Disease 2019 outcomes in 45,418 symptomatic patients with hypertension: An observational cohort study

Hypertension ◽  
2020 ◽  
Author(s):  
James P. Sheppard ◽  
Brian Nicholson ◽  
Joseph Lee ◽  
Dylan McGagh ◽  
Julian Sherlock ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Target Organ Damage ◽  
Pressure Control ◽  
Organ Damage ◽  
Adverse Outcomes ◽  
Observational Cohort ◽  
General Practices ◽  
Using Data ◽  
Stage 1 ◽  
The Impact

Hypertension has been identified as a risk factor for COVID-19 and associated adverse outcomes. This study examined the association between pre-infection blood pressure (BP) control and COVID-19 outcomes using data from 460 general practices in England. Eligible patients were adults with hypertension who were tested or diagnosed with COVID-19. BP control was defined by the most recent reading within 24months of the index date (01/01/2020). BP was defined as controlled (<130/80mmHg), raised (130/80-139/89mmHg), stage 1 uncontrolled (140/90-159/99mmHg) or stage 2 uncontrolled ({greater than or equal to}160/100mmHg). The primary outcome was death within 28 days of COVID-19 diagnosis. Secondary outcomes were COVID-19 diagnosis and COVID-19 related hospital admission. Multivariable logistic regression was used to examine the association between BP control and outcomes. Of the 45,418 patients (mean age 67 years; 44.7% male) included, 11,950 (26.3%) had controlled BP. These patients were older, had more co-morbidities and had been diagnosed with hypertension for longer. A total of 4,277 patients (9.4%) were diagnosed with COVID-19 and 877 died within 28 days. Individuals with stage 1 uncontrolled BP had lower odds of COVID-19 death (OR 0.76, 95%CI 0.62-0.92) compared to patients with well-controlled BP. There was no association between BP control and COVID-19 diagnosis or hospitalisation. These findings suggest BP control may be associated with worse COVID-19 outcomes, possibly due to these patients having more advanced atherosclerosis and target organ damage. Such patients may need to consider adhering to stricter social-distancing, to limit the impact of COVID-19 as future waves of the pandemic occur.

Abstract MP35: Blood Pressure Reductions Before Arrival at a Thrombectomy-Capable Hospital Are Associated With Neurologic Worsening in Patients With Large-Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jessica Kobsa ◽  
Ayush Prasad ◽  
Alexandria Soto ◽  
Sreeja Kodali ◽  
Cindy Khanh Nguyen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Management Strategies ◽  
Vessel Occlusion ◽  
Time Points ◽  
Good Outcome ◽  
Primary Stroke Center ◽  
Poor Outcomes ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Radiographic Data

Introduction: Decreases in blood pressure (BP) during thrombectomy are associated with infarct progression and worse outcomes. Many patients present first to a primary stroke center (PSC) and are later transferred to a comprehensive stroke center (CSC) to undergo thrombectomy. During this period, important BP variations might occur. We evaluated the association of BP reductions with neurological worsening and functional outcomes. Methods: We prospectively collected hemodynamic, clinical, and radiographic data on consecutive patients with LVO ischemic stroke who were transferred from a PSC for possible thrombectomy between 2018 and 2020. We assessed systolic BP (SBP) and mean arterial pressure (MAP) at five time points: earliest recorded, average pre-PSC, PSC admission, average PSC, and CSC admission. We measured neurologic worsening as a change in NIHSS (ΔNIHSS) from PSC to CSC >3 and functional outcome using the modified Rankin Scale (mRS) at discharge and 90 days. Relationships between variables of interest were evaluated using linear regression. Results: Of 91 patients (mean age 70±16 years, mean NIHSS 12) included, 13 (14%) experienced early neurologic deterioration (ΔNIHSS>3), and 34 (37%) achieved a good outcome at discharge (mRS<3). We found that patients with good outcome had significantly lower SBP at all five assessed time points compared to patients with poor outcome (Figure 1, p<0.05). Percent change in MAP from initial presentation to CSC arrival was independently associated with ΔNIHSS after adjusting for age, sex, and transfer time (p=0.03, β=0.27). Conclusions: Patients with poor outcomes have higher BP throughout the pre-CSC period, possibly reflecting an augmented hypertensive response. Reductions in SBP and MAP before arrival at the CSC are associated with neurologic worsening. These results suggest that BP management strategies in the pre-CSC period to avoid large reductions in BP may improve outcomes in patients affected by LVO stroke.

Abstract WP126: Association of 24-Hour Blood Pressure Parameters Post-Intravenous Alteplase With Symptomatic Intracerebral Hemorrhage

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Taha Nisar ◽  
Toluwalase Tofade ◽  
Ava Liberman ◽  
Priyank Khandelwal
Keyword(s):  
Blood Pressure ◽  
Intracerebral Hemorrhage ◽  
Treatment Time ◽  
Tertiary Care ◽  
Significant Risk ◽  
Binary Logistic Regression Analysis ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Intravenous Alteplase ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Introduction: Higher blood pressure (BP) at presentation is associated with a higher risk of symptomatic intracerebral hemorrhage (sICH) post-intravenous alteplase (IV-rtPA). We investigated the association of different BP parameters post-IV-rtPA with the development of sICH at a tertiary care center. Methods: We performed a retrospective chart review of adult patients with an acute ischemic stroke treated with IV-rtPA at a comprehensive stroke center from July 2014 to March 2018. We excluded patients who underwent mechanical thrombectomy. At the comprehensive stroke center, the BP values are documented according to standard post-IV-rtPA care guidelines. We recorded the BP values over a period of 24-hours post-IV-rtPA. A binary logistic regression analysis was performed, controlling for age, sex, pre-treatment NIHSS, atrial fibrillation, onset to treatment time, with the BP parameters as the predictors. The primary outcome was the development of sICH. SICH was defined as an intracerebral hemorrhage (ICH) that causes worsening of NIHSS score by ≥4 points post-IV-rtPA. Results: 84 patients met our inclusion criteria. 45 (53.57%) patients were male. The mean age was 63.50±15 years. 5 (5.95%) patients developed sICH. In our cohort, the BP parameters of higher maximum systolic blood pressure (SBP) (195.8±9 vs.172.22±17; OR, 1.14; 95% CI, 1.03-1.26; P 0.016), higher maximum diastolic blood pressure (DBP) (120.2±18 vs.104.76±15; OR, 1.08; 95% CI, 1.01-1.17; P 0.04), wider SBP range (79.4±20 vs.58.75±18; OR, 1.06; 95% CI, 1.01-1.12; P 0.033), wider DBP range (74.2±27 vs.47.27±15; OR, 1.11; 95% CI, 1.03-1.2; P 0.008), and coefficient variation (CV) DBP (17.7±6 vs.12.65±4; OR, 1.19; 95% CI, 1.01-1.42; P 0.048) were significantly associated with a risk of sICH post IV-rtPA. Conclusions: Our study demonstrates significant risk of sICH with higher maximum SBP and DBP, wider SBP and DBP ranges, and CV DBP post-IV-rtPA.

Abstract P689: Do Cyclic Patterns of Stroke Code Activation Occur in a Comprehensive Stroke Center?

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Edward Labin ◽  
Dawn M Meyer ◽  
Benjamin Shifflett ◽  
Brett C Meyer ◽  
Royya F Modir
Keyword(s):  
Blood Pressure ◽  
Heart Rate ◽  
Circadian Rhythm ◽  
Time Of Day ◽  
Stroke Registry ◽  
Changing Practice ◽  
Cyclic Patterns ◽  
Chi Squared ◽  
Comprehensive Stroke Center ◽  
Stroke Center

Background: The effects of circadian rhythm on stroke can include increases in morning heart rate, blood pressure, catecholamines, platelet aggregation, and hypercoagulability and might correlate with higher numbers of morning strokes. We assessed time of day and frequency of stroke code activation for a potential role of circadian rhythm in stroke risk. Methods: A retrospective analysis of prospectively collected data from an IRB approved stroke registry, from July 2004 to July 2020, was performed. Codes were included where stroke codes were activated with last known well (LKW) <6 hours to limit the effect of wake-up strokes and equalize changing practice patterns over time. Subjects were divided into four epochs based on code activation: Night (00:00-05:59), Morning (06:00-11:59), Afternoon (12:00-17:59), and Evening (18:00-23:59). Confirmed diagnosis of stroke, baseline blood pressure (SBP & DBP), heart rate (HR), and PTT were compared. Chi squared was used to compare categorical data and t test for continuous. Results: A total of 5,366 subjects were identified. Stroke code activations differed across epochs (Night n=312, 5.81%; Morning n=1439, 26.82%; Afternoon n=2207, 41.13%; Evening n=1408, 26.24%: p<0.0001). In the subset analysis of true strokes, activations also differed across epochs (Night n=125, 5.26%; Morning n= 831, 34.95%; Afternoon n=934, 39.28%; Evening n=488, 20.52%: p<0.0001). Overall, SBP was different with Evening highest and Morning lowest (x 151.6, x 148.2;p=0.01). Overall DBP showed Night highest and Afternoon lowest (x 83.9, x 81;p=0.002). Heart rate showed Night highest and Morning lowest (x 84.9, x 81.6;p=0.002). Conclusions: This study found that most stroke code activations occur in Afternoons at this CSC. This may be due to patient level characteristics, bystander availability, or other factors. Future studies should assess multi-center data and include other circadian rhythm biomarkers.

Abstract TP292: Telestroke vs Phone Consultation in Stroke Patients Eligible for Intra-Arterial Therapy

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Nicholas Osteraas ◽  
James Conners ◽  
Shawna Cutting ◽  
Sarah Song ◽  
Laurel Cherian ◽  
...  
Keyword(s):  
Female Gender ◽  
Large Vessel ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Telephone Consultation ◽  
Transfer Programs ◽  
Intravenous Tissue Plasminogen Activator ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Mean Time

Background and Objective: Intra-arterial therapy (IA) is beneficial for acute ischemic stroke patients with large vessel occlusions who have received intravenous tissue plasminogen activator (IVtPA). Telestroke has not been associated with increased IVtPA utilization rates when compared to phone consultations. We sought to determine whether telestroke improved the process of evaluation and transfer of patients who may be eligible for intra-arterial therapy (IA). Methods: The Rush telestroke program consists of an academic hub (comprehensive stroke center) that serves 10 spoke emergency departments (EDs). For sites outside of the telestroke program, the patient receives telephone consultation from the same pool of telestroke neurologists. IA therapy is considered for patients clinically suspected of having a large vessel occlusion who could potentially be treated with IA within 6 hours of last known normal (LKN). We compared IA eligible stroke patients transferred via the telestroke program to those non-telestroke transfer patients. Results: From July 1, 2013 to July 1, 2015, 126 patients were transferred from outside hospital ERs to our institution for potential IA; 6 patients were excluded for non-stroke diagnosis. Among 119 patients, 79 (66%) were evaluated via telestroke and 40 (34%) via phone consultation. There was no difference between groups for age (63.3 vs 59.3 years, p=0.14) female gender (52% vs 58%, p=0.70), hypertension (66% vs 78%, p 0.21), atrial fibrillation (27% vs 20%, p=0.50), initial arrival NIHSS (17 vs 19, p=0.12), frequency of IA (66% vs 55%, p=0.31), mean time from LKN to IVtPA administration (139 vs 138 minutes, p=0.96), mean time from IVtPA administration to arrival (106 vs 94 minutes, p=0.31), and mean time from arrival to IA start (35 vs 31 minutes, p=0.44). More patients who were evaluated via telestroke received TPA compared to those evaluated via phone (80% vs 63%, p<0.05). Conclusions: Telestroke improves the evaluation of IA eligible stroke transfer patients by increasing the rates of IVtPA compared with telephone consultation alone. Comprehensive stroke centers may benefit patients by incorporating telestroke systems into their IA transfer programs.

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