Blood pressure fluctuates, be careful of brain bleeding! It's a good idea!

For patients with ICH, it is very important to control blood pressure fluctuation.cerebral hemorrhage refers to primary non traumatic cerebral parenchymal hemorrhage (ICH), which belongs to hemorrhagic stroke with subarachnoid hemorrhage.studies have shown that hypertension is associated with increased rebleeding events and increased mortality in ICH patients.blood pressure variability (BPV) is an independent predictor of early hematoma enlargement, neurological deterioration, and patient death. Hematoma enlargement is the main clinical feature of most ICH patients within 24 hours, which can compress the nearby brain tissue structure, resulting in rapid deterioration of neurological function and consciousness, and even death.nevertheless, the optimal strategy and target of blood pressure reduction in acute and subacute stroke are still controversial.the 2015 AHA / ASA guidelines recommend that it may be safe to reduce SBP to & lt; 140 mmHg in patients with ICH whose systolic blood pressure (SBP) is between 150 and 220 mmHg.however, no specific antihypertensive drug has been approved to achieve this goal.at present, labetalol, hydralazine and nicardipine have been recommended as the initial treatment for acute nerve injury.compared with nicardipine, the half-life of labetalol and hydralazine is relatively long, which is difficult to meet the clinical needs of rapid control of SBP.however, a study published in neurocrit care has made a detailed comparison of the effects of intravenous anti hypertensive drugs such as nicardipine on BPV [1].Article Title: Nicardipine can reduce blood pressure variability in patients with ich.01 the study confirmed that nicardipine significantly reduced BPV and improved the prognosis of patients with ICH. The researchers divided the patients into two groups according to the antihypertensive drugs taken within 24 hours after the occurrence of nicardipine: patients receiving intravenous injection of labetalol and / or hydralazine were classified as intravenous injection group, and received nicardipine ± labetalol and / or hydralazine propionate The patients with intravenous injection of azine were classified into the intravenous maintenance + injection group (hereinafter referred to as nicardipine group).nicardipine group was given high-dose intravenous injection of labetalol 10-20 mg or hydralazine 10-20 mg, followed by intravenous drip of nicardipine at 5 mg / h, and titrated after two high-dose administration.the main purpose of the test was to compare the changes of systolic blood pressure within 24 hours between the two groups.of the 272 patients included, 164 patients in the IV group did not receive nicardipine treatment during the 24-hour study period, while 108 patients in the nicardipine group received nicardipine treatment during the 24-hour study period.the characteristics of patients are shown in Table 1.the patients were mainly white (87.9%), with an average age of 69 years.our patient sample predicted a 30 day mortality rate of 26% [2]. The vast majority of patients (95.2%) were admitted to the neuroscience intensive care unit. Table 1: patient characteristics can be seen from table 1, 88.9% of patients had hypertension before admission. on admission, the Glasgow Coma Scale scores were fairly average, with about one third of the patients with scores of 3-11, 12-14 and 15 respectively. it is worth noting that the median ICH Score in the IV maintenance + bolus group was lower than that in the nicardipine group, indicating that the mortality rate of patients receiving intravenous infusion may be higher. it was pointed out that the SBP target of nicardipine group was set at & lt; 140 mmHg, and all patients were sent to ICU as required and received nicardipine treatment in ICU. Figure 1: mean blood pressure variability. Results from Figure 1, the systolic blood pressure decreased significantly within 6 hours in nicardipine group, and the time to reach the target systolic blood pressure was shorter. and the decrease of BPV was significantly higher than that of intravenous injection group, and the 24-hour fluctuation range was small. relatively speaking, the systolic blood pressure decreased slowly in patients with intravenous injection of labetalol and hydralazine, and the decrease range of BPV was smaller and the fluctuation was larger. it can be seen that in ICH patients treated with nicardipine, SBP decreased to the target value for a longer time, the fluctuation of blood pressure was smaller, and the possibility of hypotension was lower (P = 0.052). as mentioned earlier, BPV is an independent predictor of early hematoma enlargement and neurological deterioration, as well as death in patients with ICH. Therefore, it is essential to take antihypertensive treatment and take appropriate measures to reduce the adverse prognosis caused by changes in BPV. 02 although there are limitations, it is important to control BPV. Although the researchers mentioned in the article that although this is one of the largest studies describing BPV in the literature, the interpretation of our results is limited due to the retrospective study design, which only focuses on a single clinical center and the sample size is relatively small. however, the researchers also concluded that patients with ICH who received labetalol and / or did not receive nicardipine had more changes in BPV within 24 hours after admission than patients treated with nicardipine and / or nicardipine. this study shows that nicardipine intravenous maintenance / bolus can make the blood pressure drop more stable in patients with ICH than intravenous injection of labetalol or hydrazine alone, and can avoid the harmful effects of excessive BPV on these patients. although nicardipine has not been shown to be beneficial to ICH in randomized clinical trials, BPV has been shown to be harmful to ICH. Therefore, it is advisable to use titratable intravenous infusion carefully to reduce blood pressure and its fluctuation regardless of the target blood pressure. time interaction time Q: the results of this study show that nicardipine can improve the blood pressure variability of patients with spontaneous cerebral hemorrhage compared with labetalol and hydralazine, and the time to reach the target SBP is shorter. What do you think are the causes of this result (it can be described in terms of pharmacokinetics, pharmacological effects, etc.), and do you have any experience in the application of nicardipine in clinical work? What advantages does it have compared with other horizon drugs? Nicardipine can help ICH patients to control their blood pressure better. Lu Fengxia, deputy chief physician of cardiac surgery, Second Affiliated Hospital of Nanjing Medical University, has shown that nicardipine can improve the BPV of patients with spontaneous cerebral hemorrhage, and the time to reach the target SBP is shorter than that of labetalol and hydralazine. As a dihydropyridine calcium channel blocker (CCB), nicardipine can effectively inhibit the transmembrane calcium influx of myocardium and vascular smooth muscle, and it does not change the blood calcium concentration of patients after medication, and has strong vascular selectivity. nicardipine mainly dilates the arterioles and spasmodic vessels, which is easy to gather the micro arteries in the cerebral ischemic area and promote the normal blood supply in the ischemic area. The blood vessels in the bleeding area will not accumulate and expand. studies have shown that for ICH patients, blood pressure drop to a reasonable level can reduce the pressure difference between inside and outside the blood vessels at the bleeding site and relieve cerebral hemorrhage. to reduce blood pressure and improve cerebral circulation, nicardipine has been recommended by the guidelines. Wang Bingbing nicardipine, chief physician of Neurosurgery of the Fifth Affiliated Hospital of Zhengzhou University, is the recommended intravenous antihypertensive drug for patients with subarachnoid hemorrhage at home and abroad. in the treatment of subarachnoid hemorrhage hypertension, nicardipine can quickly and steadily reduce blood pressure, improve the prognosis of subarachnoid hemorrhage, ensure cerebral perfusion, and effectively reduce SBP and diastolic blood pressure. studies have confirmed that nicardipine can improve cerebral circulation, cerebral vasospasm, increase local cerebral blood flow, do not affect local cerebral tissue partial pressure, and do not increase intracranial pressure. as a new type of dihydropyridine CCB, nicardipine has the similar effect as nifedipine. Nicardipine can increase the level of camp by inhibiting the influx of calcium ion and camp phosphodiesterase, thus resulting in vasodilation and obvious vasodilation, especially in cerebral vessels and coronary arteries. nicardipine is a CCB antihypertensive drug, which can dilate arterioles and improve blood supply to ischemic areas. at the same time, nicardipine did not accumulate and dilate the bleeding vessels in a large amount. nicardipine has a short half-life of about 3 hours, so on the one hand, it has a faster onset time and can reduce blood pressure to the target value faster; on the other hand, the clearance time in vivo is faster, the dose response is predictable, and the probability of hypotension is small. moreover, nicardipine is highly selective to vascular smooth muscle, can dilate renal artery, coronary artery and cerebral artery, improve blood perfusion of target organs, reduce afterload, improve cardiac function, and protect blood vessels, myocardium and nerve cells. clinical experience sharing Tao Jun, an attending physician from the Department of Cardiology, Sun Yat Sen Memorial Hospital, Sun Yat sen University, first pointed out that nicardipine has the advantages of rapid onset, faster blood pressure compliance, strong controllability, low incidence of hypotension, and sufficient evidence-based evidence. Nicardipine is an ideal choice for patients with cardiovascular diseases. Wang Xiao, an attending physician from the emergency department of the First Affiliated Hospital of Kunming Medical University, said that for patients with acute hypertension, the treatment principles include safe and stable blood pressure drop of no more than 25% within 1 hour, to 160 / 100 mmHg within 6 hours, and to 130 / 90 mmHg within 24-48 hours. nicardipine, as the first-line drug recommended by the guideline, can meet the clinical needs of patients with acute hypertension and is the preferred choice. Zhang Tao, chief physician from the emergency department of Fuwai Hospital, Chinese Academy of Medical Sciences, added that nicardipine, as a commonly used intravenous antihypertensive drug, has a wide range of application, strong antihypertensive effect, clear dose-response relationship, easy to adjust the dose, has little impact on intracranial pressure, and does not affect liver and kidney functions. It is also suitable for patients with renal insufficiency. References: [1] poiant, J.O., Kuper, P.J., Mara, K.C. et al. Nicardipine reduce blood pressure variability after spontaneous intrathecal hemorhage. Neurocrit 30, 118 – 125 (2019). [2] Hemphill JC, bonovich DC, besmirtis L, Manley GT, Johnston sc. the ICH Score: a simple, reliable grading scale for intracerebral heating. Stroke 2001;32(4):891 7.