3 minutes to focus on blood pressure management in patients with acute ischemic stroke and heart disease|Guideline consensus

The annual incidence of stroke in my country is 250/100,000, and the annual incidence of coronary heart disease events is 50/100,000.

Stroke and coronary heart disease are closely related, and the incidence of stroke is higher than that of coronary heart disease.
The two have a common pathophysiological basis-atherosclerosis, and hypertension is the most important independent risk factor for atherosclerotic disease.

Therefore, active and reasonable control and management of blood pressure is the cornerstone of effective prevention and treatment of cardiovascular and cerebrovascular diseases, and is also an important link in the theory of brain-heart simultaneous treatment.

At present, there are many different understandings of blood pressure management for cardiovascular and cerebrovascular diseases, and there is a lack of clear clinical research evidence for reference.

In view of this, domestic experts in this field have formed an expert consensus on blood pressure management in patients with acute ischemic stroke (AIS) combined with heart disease for reference.

 Blood pressure management of AIS combined with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) ➤Hypertensive principle: It is recommended to reduce blood pressure by no more than 15% within the first 24 hours.
In case of emergency, follow the protection to make the condition more serious The principle of organ-based management is that if the AIS is more serious, the blood pressure management is mainly to protect the brain, and if the ACS is more serious, the blood pressure management is mainly to protect the heart.

 ➤The timing and goal of lowering blood pressure in acute ischemic stroke combined with ACS: First use evidenced cardioprotective drugs (renin angiotensin system inhibitors and β-blockers) in ACS, and target blood pressure <140/90mmHg , Whether the blood pressure can be reduced to <130/80mmHg depends on the appropriate situation of AIS.

Therefore, when the two coexist, the stroke criteria should be taken into consideration and the stroke criteria should be used as a reference.

 ➤The timing and goal of reducing blood pressure in acute ischemic stroke combined with CCS: Considering that it may be safe to reduce blood pressure to 140/90mmHg in the acute phase of ischemic stroke, it is recommended that blood pressure be controlled at 140/90mmHg for patients with CCS.
90mmHg, but the lower limit is not clear at present, it should be combined with the etiological classification of patients with ischemic stroke and the stenosis of the intracranial and extracranial arteries.

 ➤Antihypertensive drugs and methods of administration: In view of the high risk of AIS combined with ACS hypertension, intravenous drug treatment is often required.
Commonly used drugs are: nicardipine, urapidil, and nitroglycerin (forbidden for high intracranial pressure; no contraindications Preferred).

For AIS combined with CCS, oral drugs can be considered, and drugs with clinical research evidence should be selected, such as ACEI/ARB, long-acting CCBs, β-blockers and diuretics.

 Blood pressure management of AIS combined with heart failure ➤ The timing and goal of blood pressure reduction of AIS combined with acute heart failure: In the absence of new ischemic manifestations related to blood pressure reduction, blood pressure should be reduced as much as possible to the patient's heart function tolerable After load level.

After starting antihypertensive therapy, it is generally recommended that the mean arterial pressure be reduced by 15% to 25% from the initial level in the first 1 hour.

 If the cardiac function is tolerable and there are no new symptoms and signs of cerebral ischemia related to antihypertensive treatment, the blood pressure will continue to be gradually reduced within 2 to 6 hours, and the blood pressure target is recommended to be 160/100mmHg; close assessment of cerebral ischemia and If the heart function is tolerable, it is recommended to gradually stabilize the blood pressure in a safe range according to the patient's condition in the follow-up treatment.

If there are no contraindications, blood pressure can be controlled at a normal level within 24 to 48 hours, but generally not less than 130/80mmHg.

 ➤The timing and goal of blood pressure reduction for AIS combined with chronic heart failure: blood pressure rises significantly after AIS.
Those with cardiac insufficiency should actively control blood pressure to relieve symptoms and improve heart function.

For those who do not receive intravenous thrombolysis or intravascular treatment, such as blood pressure ≥200/110mmHg, antihypertensive treatment is recommended.

In the first 24 hours after AIS, the mean arterial pressure can be reduced by 15% compared to the baseline level; subsequent blood pressure can be gradually controlled to <140/90mmHg according to changes in cardiac function and cerebral perfusion.

 ➤Antihypertensive drugs and methods of administration: Blood pressure increases significantly after AIS, such as acute heart failure or pulmonary edema, blood pressure needs to be controlled as soon as possible to relieve symptoms and improve heart function.
It is recommended to use antihypertensive drugs intravenously.

Patients with chronic cardiac insufficiency but not accompanied by acute target organ damage should control blood pressure appropriately and use antihypertensive drugs as appropriate.

Preferentially choose antihypertensive drugs that help improve cardiac function and long-term cardiovascular prognosis without adversely affecting cerebral blood perfusion, including angiotensin system inhibitors (ACEI and ARB), long-acting dihydropyridine CCB, and diuretics Agents, β-receptor blockers and aldosterone receptor antagonists.

 Clinical recommendations for blood pressure management of AIS combined with heart disease ➤ Recommendations for acute ischemic stroke combined with ACS: It is recommended to reduce blood pressure by no more than 15% within the first 24h, and it is safe to reduce to 140/90mmHg 48h after the onset; when combined with ACS , According to the critical situation, priority should be given to the heavier organs in the heart and brain.

 ➤Recommendation for acute ischemic stroke combined with CCS: blood pressure can be controlled at 140/90mmHg, but the lower limit is not clear at present.
It should be determined by combining the etiology of patients with ischemic stroke and the stenosis of the intracranial and extracranial arteries.

 ➤Recommendation for acute ischemic stroke combined with acute heart failure: It is recommended that the mean arterial pressure be reduced by 15% to 25% from the initial level in the first 1 hour; the blood pressure should be gradually reduced to <160/100mmHg within 6 hours; if there is no contraindication, it can be used within 24 hours.
Keep blood pressure at a normal level within ~48h, but generally not lower than 130/80mmHg; after 48h, it is recommended to actively control blood pressure.

 ➤Recommendations for acute ischemic stroke combined with chronic heart failure: The average arterial pressure can be reduced by 15% from the baseline level within the first 24 hours after AIS; the blood pressure can be gradually controlled to a level that the patient's heart function can tolerate according to the cerebral perfusion status.

 ➤For patients in the recovery phase of ischemic stroke, the blood pressure control target is <140/90mmHg.

The type and dosage of antihypertensive drugs and the target value for antihypertensive should be individualized.
It is recommended to choose ACEI or ARB, long-acting CCB and diuretic antihypertensive drugs.

 Yimaitong is compiled from: Hypertension Branch of China Association for the Promotion of International Medical and Health Care, Beijing Association for Prevention and Treatment of Cerebrovascular Diseases.
Expert consensus on blood pressure management in patients with acute ischemic stroke and heart disease[J].
Chinese Journal of Internal Medicine,2021,60(4 ): 306-313.