Opinion statement
Widespread reluctance to treat hypertension during acute stroke is based on historical accounts of unfavorable outcomes of treatment that were badly done: therapies that cannot be controlled, such as sublingual nifedipine, oral or intramuscular antihypertensive drugs may drop blood pressure precipitously, leading to worsening of ischemia. Case fatality in stroke obeys a U-shaped relationship: blood pressures that are either too low or too high are associated with worse outcomes both in ischemic stroke and in intracerebral hemorrhage. Very high blood pressures should be lowered in acute stroke, and there are some circumstances in which high blood pressure must be treated despite the presence of stroke. To avoid worsening of ischemia by reduction in cerebral blood flow, it is necessary to treat high blood pressure in acute stroke with drugs that can be controlled; this usually means giving drugs by intravenous infusion; however, there is recent evidence that transdermal administration of nitrates, which can be removed if pressure is too low, is a convenient alternative that does not reduce cerebral blood flow in acute stroke.
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References and Recommended Reading
Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA: Blood pressure and clinical outcomes in the International Stroke Trial. Stroke 2002, 33:1315–1320.
Okumura K, Ohya Y, Maehara A, et al.: Effects of blood pressure levels on case fatality after acute stroke. J Hypertens 2005, 23:1217–223.
Dandapani BK, Suzuki S, Kelley RE, et al.: Relation between blood pressure and outcome in intracerebral hemorrhage. Stroke 1995, 26:21–24.
Adams H, Adams R, Del ZG, Goldstein LB: Guidelines for the early management of patients with ischemic stroke: 2005 guidelines up date a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke 2005, 36:916–923.
Yatsu FM, Zivin J: Hypertension in acute ischemic strokes. Not to treat. Arch Neurol 1985, 42:999–1000.
Spence JD, Del Maestro RF: Hypertension in acute ischemic strokes. Treat. Arch Neurol 1985, 42:1000–1002.
Bath P, Chalmers J, Powers W, et al.: International Society of Hypertension (ISH): statement on the management of blood pressure in acute stroke. J Hypertens 2003, 21:665–672.
Chalmers J: Blood pressure and stroke: a continuing debate. J Hypertens 2006, 24:1249–1251.
Willmot M, Ghadami A, Whysall B, et al.: Transdermal glyceryl trinitrate lowers blood pressure and maintains cerebral blood flow in recent stroke. Hypertension 2006, 47:1209–1215.
Bath PM: Major ongoing stroke trials. Efficacy of Nitric Oxide in Stroke (ENOS) trial [abstract]. Stroke 2001, 32:2450–2451.
Doba N, Reis DJ: Acute fulminating neurogenic hypertension produced by brainstem lesions in the rat. Circ Res 1973, 32:584–593.
Nathan MA, Reis DJ: Fulminating arterial hypertension with pulmonary edema from release of adrenomedullary catecholamines after lesions of the anterior hypothalamus in the rat. Circ Res 1975, 37:226–235.
Mazey RM, Kotchen TA, Ernst CB: A syndrome resembling pheochromocytom a following a stroke. Report of a case. JAMA 1974, 230:575–577.
Willmot M, Leonardi-Bee J, Bath PM: High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension 2004, 43:18–24.
Sprigg N, Gray LJ, Bath PM, et al.: Relationship between outcome and baseline blood pressure and other haemodynamic measures in acute ischaemic stroke: data from the TAIST trial. J Hypertens 2006, 24:1413–1417.
Halsey JH Jr, O’Brien MD: Role of hypertension in pathogenesis of cerebral infarction edema. Adv Neurol 1980, 28:317–321.
Hayakawa T, Waltz AG, Jacobson RL: Hypertension and acute focal cerebral ischemia. Infarction and edem a after occlusion of a middle cerebral artery in cats. Stroke 1979, 10:263–267.
Karki A, Westergren I, Widner H, et al.: Tirilazad reduces brain edem a after middle cerebral artery ligation in hypertensive rats. Acta Neurochir Suppl (Wien) 1994, 60:310–313.
Paulson OB, Lassen NA, Skinhoj E: Regional cerebral blood flow in apoplexy without arterial occlusion. Neurology 1970, 20:125–138.
Strandgaard S: Autoregulation of cerebral blood flow in hypertensive patients. The modifying influence of prolonged antihypertensive treatment on the tolerance to acute, drug-induced hypotension. Circulation 1976, 53:720–727.
van HJ, Burggraaf K, Danhof M, et al.: Negligible sublingual absorption of nifedipine. Lancet 1987, 2:1363–1365.
Schrader J, Luders S, Kulschewski A, et al.: The ACCESS Study: evaluation of Acute Candesartan Cilexetil Therapy in Stroke Survivors. Stroke 2003, 34:1699–1703.
Hackam DG, Thain LM, Abassakoor A, et al.: Trapped renal arteries: functional renal artery stenosis due to occlusion of the aorta in the arch and below the kidneys. Can J Cardiol 2001, 17:587–592.
Spence JD: Management of resistant hypertension in patients with carotid stenosis: high prevalence of renovascular hypertension. Cerebrovasc Dis 2000, 10:249–254.
Spence JD: Individualized therapy for hypertension. Hypertension 2006, 47:e11.
Spence JD: Physiologic tailoring of therapy for resistant hypertension: 20 years’ experience with stimulated renin profiling. Am J Hypertens 1999, 12(11 Pt 1):1077–1083.
Biglieri EG, Kater CE, Arteaga EE: Primary aldosteronism is comprised of primary adrenal hyperplasia and adenoma. J Hypertens Suppl 1984, 2:S259–S261.
Baker EH, Duggal A, Dong Y, et al.: Amiloride, a specific drug for hypertension in black people with T594M variant? Hypertension 2002, 40:13–17.
Wallach L, Nyarai I, Dawson KG: Stimulated renin: a screening test for hypertension. Ann Intern Med 1975, 82:27–34.
Butterworth RJ, Cluckie A, Jackson SH, et al.: Pathophysiological assessment of nitric oxide (given as so dium nitroprusside) in acute ischaemic stroke. Cerebrovasc Dis 1998, 8:158–165.
Rindone JP, Sloane EP: Cyanide toxicity from sodium nitroprusside: risks and management. Ann Pharmacother 1992, 26:515–519.
Alaniz C, Watts B: Monitoring cyanide toxicity in patients receiving nitroprusside therapy. Ann Pharmacother 2005, 39:388–389.
Gogbashian A: Nitroprusside in critically ill patients with aortic stenosis. N Engl J Med 2003, 349:811–813.
Khot UN, Novaro GM, Popovic ZB, et al.: Nitroprusside in critically ill patients with left ventricular dysfunction and aortic stenosis. N Engl J Med 2003, 348:1756–1763.
Sinaiko AR: Hypertension in children. N Engl J Med 1996, 335:1968–1973.
Spence JD: Treating hypertension in acute stroke: a better arrow for the quiver. Hypertension 2006, 47:1051.
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Spence, J.D. New treatment options for hypertension during acute ischemic or hemorrhagic stroke. Curr Treat Options Cardio Med 9, 242–246 (2007). https://doi.org/10.1007/s11936-007-0019-0
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DOI: https://doi.org/10.1007/s11936-007-0019-0