Dajia Online: How to manage blood pressure in patients with cerebral hemorrhage

For reference only for medical professionals, staged and rhythmic blood pressure reduction should be the way to manage blood pressure in patients with cerebral hemorrhage
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Spontaneous cerebral hemorrhage is the second most common type of stroke after ischemic stroke.
In China, cerebral hemorrhage accounts for about 18.
8%-47.
6% of all strokes, and its 30-day mortality rate is as high as 35%~ 52% [1], blood pressure management after intracerebral hemorrhage is an important treatment strategy to improve patient outcomes
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On January 29th, in the first phase of the "Urgent and Heavy Three-person Travel - Big Coffee Online" project held online, under the auspices of Professor Qu Xin of Xuanwu Hospital of Capital Medical University, Professor Wang Ning of Xuanwu Hospital of Capital Medical University, Harbin Medical University Prof.
Shi Huaizhang from the First Affiliated Hospital discussed and discussed in depth the blood pressure management of patients with cerebral hemorrhage from the perspective of evidence-based evidence and drug application experience
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Blood pressure management is closely related to the prognosis of patients with cerebral hemorrhage, and urgent intervention is needed.
Professor Wang Ning first pointed out that cerebral hemorrhage is one of the important types of stroke.
Global data shows that it accounts for about 10% of all stroke types.
It is estimated that the proportion of Chinese patients is higher, which can be reach 15%~20%
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However, due to the vast area, there are still some differences in the incidence rate in different places, and this difference is related to various factors such as living habits
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Intracerebral hemorrhage is a destructive disease to brain tissue.
Its risk factors, such as hyperglycemia and hyperlipidemia, are difficult to control in a short period of time, but blood pressure can be controlled in the acute phase of the disease
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Due to factors such as stress response and increased intracranial pressure, patients with cerebral hemorrhage are generally accompanied by increased blood pressure, and the increased blood pressure will promote the progress of cerebral hemorrhage, resulting in poor prognosis.
Therefore, blood pressure management in patients with cerebral hemorrhage should be emphasized
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Professor Shi Huaizhang analyzed the north-south difference in the incidence of cerebral hemorrhage and pointed out that the incidence of cerebral hemorrhage is higher in the north
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Professor Shi Huaizhang's center needs to treat about 3,000 patients with cerebral hemorrhage every year, of which 800-1,000 have received surgical treatment
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Based on the high mortality and high disability rate of cerebral hemorrhage, active intervention is very important
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Professor Shi Huaizhang emphasized that the main factors affecting the prognosis of patients with cerebral hemorrhage include two aspects: bleeding location and bleeding volume
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Although doctors cannot intervene in the bleeding site, active treatment in the acute phase may control or even reduce the amount of bleeding, and blood pressure control is one of the important strategies, especially the control of systolic blood pressure helps control the amount of bleeding
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One study[2] performed computed tomography (CT) scans at baseline and 24 hours after the onset of cerebral hemorrhage, and found that elevated systolic blood pressure (above 180 mmHg) could predict hematoma enlargement, and elevated systolic blood pressure was independent of patient prognosis.
Correlation, suggesting the need to actively intervene in post-onset blood pressure elevation
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Blood pressure management in patients with cerebral hemorrhage: rhythmic and step-by-step Professor Qu Xin also agrees that blood pressure management has an important impact on the prognosis of patients with cerebral hemorrhage, and blood pressure control goals are very important, and too high or too low blood pressure goals are not advisable
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Professor Wang Ning pointed out that after the onset of cerebral hemorrhage, the goal of blood pressure management is not as low as possible.
Maintaining a certain blood pressure helps to maintain normal cerebral perfusion and blood perfusion of other important organs.
Therefore, it is necessary to finely control the blood pressure target.
It can ensure the blood flow of the brain tissue around the hematoma without increasing the volume of the hematoma
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The ADAPT study [3] suggests that reducing systolic blood pressure to <140 mmHg within a few hours after ICH does not reduce cerebral blood flow and cerebral perfusion pressure around the hematoma, nor does it increase cerebral ischemic events, which is worthy of clinical reference
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In clinical practice, it can be found that the systolic blood pressure of most patients is above 160 mmHg, and it should be controlled to 140 mmHg as much as possible at this time
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In addition, patients with cerebral hemorrhage often have high blood pressure at baseline, and their kidneys, hearts and other organs have adapted to higher blood pressure levels.
Target organ damage to patients
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Based on various evidence-based medical evidence, relevant guidelines also set the systolic blood pressure target value at around 140 mmHg, and recommend rhythmically lowering blood pressure according to the patient's baseline blood pressure
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For example, the "Guidelines for Diagnosis and Treatment of Intracerebral Hemorrhage in China (2019)" [1] clearly pointed out that for hospitalized patients with systolic blood pressure between 150 and 220 mmHg, in the absence of acute blood pressure contraindications, the blood pressure should be lowered to 130 ~ 130 within a few hours.
140 mmHg is safe (Class II recommendation, Level B evidence)
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For patients with intracerebral hemorrhage with systolic blood pressure >220 mmHg, continuous intravenous infusion of drugs may be reasonable to control blood pressure with close blood pressure monitoring, with a systolic blood pressure target of 160 mmHg (Class II recommendation, Level of evidence D)
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Professor Shi Huaizhang agreed that lower blood pressure is not always better, and pointed out that too low blood pressure may cause irreversible target organ damage to patients
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In addition, the ATACH study [4], the INTERACT-1 study [5], and the INTERACT-2 study [6] have also successively suggested that reducing systolic blood pressure to <140 mmHg may be a more appropriate target value
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For patients with cerebral hemorrhage with extremely high blood pressure (systolic blood pressure > 220 mmHg), there is a lack of data on the safety and efficacy of active antihypertensive therapy.
A systolic blood pressure of 160 mmHg can be used as a reference target
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In terms of specific blood pressure reduction strategies, rhythmic and step-by-step blood pressure reduction is recommended by the guidelines
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For example, the "Expert Consensus on Diagnosis and Treatment of Emergency Hypertension in China" [7] pointed out that for patients with spontaneous cerebral hemorrhage with a systolic blood pressure of 150-220 mmHg and no contraindications to acute antihypertensive treatment, it is safe to reduce the systolic blood pressure to 140 mmHg in the acute phase
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A rhythmic three-stage blood pressure reduction can be adopted.
The first goal is to reduce blood pressure to a safe level within 30 to 60 minutes to avoid abrupt reduction in blood pressure, resulting in reduced autoregulation space of the vascular bed, insufficient tissue perfusion, and/or infarction.
Intravenous drugs are generally used at this stage
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Thereafter, the rate of intravenous administration was gradually reduced, and oral medication was added to lower blood pressure to the second and third goals
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Professor Qu Xin concluded that patients with cerebral hemorrhage should maintain a certain systolic blood pressure to prevent rebleeding and maintain cerebral perfusion
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Choose different antihypertensive strategies and target values ​​according to the patient's baseline blood pressure, and reduce blood pressure rhythmically, steadily and safely
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Optimal control of blood pressure in patients with cerebral hemorrhage with intravenous preparations After the antihypertensive strategy is clarified, in the face of numerous antihypertensive drugs, how should one choose the best antihypertensive drugs with different mechanisms and pathways of action? In this regard, Professor Wang Ning believes that in the acute phase of cerebral hemorrhage, the preferred dosage form should be intravenous preparations
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Among the "a hundred flowers blooming" drugs, select drugs with stable pharmacokinetics, safe and effective antihypertensive drugs, and apply them after weighing the pros and cons
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For example, although sodium nitroprusside is widely used, due to its dilating effect on veins, it is easy to cause an increase in pulse pressure and a sharp drop in blood pressure, so it is not a suitable choice for patients with cerebral hemorrhage
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The 2020 International Society of Hypertension (ISH) Global Hypertension Practice Guidelines [8] states that intravenous labetalol and nicardipine are generally safe for use in all hypertensive emergencies and are applicable throughout the management process
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In clinical practice, nicardipine is also a commonly used drug that can quickly and steadily lower blood pressure, which is helpful for patients with acute cerebral hemorrhage to reach the blood pressure target
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Of course, in application, we also need to observe the changes of the patient's condition from a holistic perspective
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For patients with rapid heart rate and high cardiac oxygen consumption, beta-blockers can be considered
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For patients with intracranial hypertension, nervousness, and difficulty in calming due to intubation and other stimuli, sedative and analgesic drugs should be used in a timely manner to help achieve blood pressure reduction
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Professor Shi Huaizhang pointed out that the five characteristics of rapidity, stability, controllability, less rebound, and fewer side effects are what we hope intravenous antihypertensive drugs have.
The influx of calcium ions achieves the purpose of lowering blood pressure through vasodilation
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Since nicardipine has a 30,000-fold stronger effect on vascular smooth muscle than myocardium (selectively dilates blood vessels), its antihypertensive effect is highly specific and has target organ protection.
It is a commonly used intravenous antihypertensive drug after cerebral hemorrhage
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Conclusion In patients with intracerebral hemorrhage, we need to administer rapid and steady antihypertensive therapy, with a phased and rhythmic reduction of systolic blood pressure to 140 or 160 mmHg according to the baseline blood pressure level
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In terms of drug selection, intravenous preparations such as nicardipine have the characteristics of rapid, effective and stable blood pressure reduction, and the antihypertensive effect can be controlled, and are worthy of the preferred antihypertensive preparations
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In the application, we should also evaluate the patient's situation with a holistic concept, and add other supportive therapy in a timely manner, so that the patient can successfully pass through the acute phase of cerebral hemorrhage and obtain a satisfactory prognosis
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References: [1] Neurology Branch of Chinese Medical Association, Cerebrovascular Disease Group of Neurology Branch of Chinese Medical Association.
Guidelines for the diagnosis and treatment of cerebral hemorrhage in China (2019).
Chinese Journal of Neurology, 2019, 52(12): 994-1005.
[2]Rodriguez-Luna D, Piñeiro S, Rubiera M, et al.
Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage.
Eur J Neurol.
2013; 20(9): 1277-83.
[3] Butcher KS, Jeerakathil T, Hill M, et al.
The intracerebral hemorrhage acutely decreasing arterial pressure trial.
Stroke, 2013,44(3): 620-626.
[4]Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators.
Antihypertensive treatment of acute cerebral hemorrhage.
Crit Care Med, 2010, 38(2): 637-648.
[5]Anderson CS, Huang Y, Wang JG, et al.
Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial[J].
Lancet Neurol, 2008, 7(5): 391-399.
[6] Anderson CS, Heeley E, Huang Y, et al.
Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.
N Engl J Med, 2013, 368(25): 2355-2365.
[7] Emergency Physician Branch of Chinese Medical Doctor Association, China Hypertension League, Beijing Hypertension Prevention Association.
China Expert consensus on emergency hypertension diagnosis and treatment (2017 revision), China Emergency Medicine, 2018, 38(1): 1-13.
[8]Unger T, Borghi C, Charchar F, et al.
2020 International Society of Hypertension Global Hypertension Practice Guidelines.
Hypertension.
2020; 75(6): 1334-1357.
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