Stable blood pressure reduction + brain function protection, nicardipine is preferred for blood pressure reduction after cerebral hemorrhage

It is only for medical professionals to read and reference, and it is recommended by the guidelines.
Why is nicardipine preferred? This study is worth a read
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Hypertensive intracerebral hemorrhage is one of the most serious complications of hypertension, accounting for 15% of all types of stroke [1]
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For critically ill patients, creating conditions for surgical intervention at the same time as medical treatment, and timely and active treatment is expected to save the patient's life and promote the recovery of their neurological function
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However, the benefits of surgery come with risks
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Postoperative hypertension may directly lead to postoperative intracranial hemorrhage and cerebral edema, thereby increasing perioperative morbidity and mortality
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Therefore, good postoperative blood pressure management is of great significance for ideal prognosis
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Postoperative blood pressure is not as low as possible.
The decrease in mean arterial pressure (MAP) cannot exceed the lower limit of cerebral blood pressure self-regulation, otherwise cerebral blood perfusion will not be guaranteed, resulting in secondary injury [2]
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Both nicardipine and urapidil, which are recommended by the European Society of Cardiology/European Society of Hypertension[3] and the American Heart Association/American Stroke Association[4] as the preferred intravenous drugs for hypertensive intracerebral hemorrhage, can control blood pressure at the same time.
Increase cerebral blood flow
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But which is more suitable as the preferred drug for blood pressure management after hypertensive intracerebral hemorrhage? The same is recommended, but it can also be selected as the best.
Researchers from Guangdong have explored this issue [2]
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The study randomized 60 patients who were admitted to hospital within 3 hours of onset of hypertensive intracerebral hemorrhage, underwent surgery within 24 hours, and had postoperative blood pressure >165/95 mmHg, 30 patients in the nicardipine group and 30 patients in the urapidil group.

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There were no statistically significant differences between the two groups in gender, age, hematoma size, and surgical approach
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Observation indicators included the number of patients in the two groups whose blood pressure dropped to the target value 1 hour and 2 hours after medication, the average blood pressure after 2 hours, and the change of heart rate before and after medication; cranial computed tomography (CT) scans before surgery, 1 week, and 4 weeks after surgery.
) showed the size of the hematoma + edema area; the Clinical Neurological Impairment Score (CSS) score of stroke patients within 24 hours, 1 week, 4 weeks and 12 weeks of admission, and the scale of daily living activities after 12 weeks
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After surgery, both groups of patients received dehydration, anti-infection and neurotrophic routine treatment, and the blood pressure target value was 160/90 mmHg
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The usage of the two drugs is as follows: nicardipine 10 mg+250 ml 5% glucose injection/250 ml 0.
9% normal saline intravenously, the initial drip rate is 30 μg/min, and then the drip rate is adjusted according to the patient’s blood pressure, ranging from 15-20 μg /min; urapidil was intravenously injected at first 25 mg, followed by intravenous drip of urapidil 200 mg+250 ml 5% glucose injection/250 ml 0.
9% normal saline, starting at a drip rate of 30 μg/min, and then adjusted with the patient’s blood pressure.
speed, in the range of 10-15 μg/min
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Both drugs were used until blood pressure dropped to a predetermined range for 7 days
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Faster, more stable, and better prognosis results showed that both systolic and diastolic blood pressure gradually decreased after administration of both drugs.
After 1 hour, the proportion of nicardipine and urapidil groups reaching the standard was 70% and 60%, respectively, and 2 hours later.
The proportions of those who reached the standard afterward were 90% and 66.
7%, respectively, and the differences between the groups at the two time points were statistically significant
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In terms of volume improvement of intracranial hematoma + edema, the volume of the two groups of patients was significantly improved after treatment, and the clinical symptoms were improved
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In the comparison between groups, no matter at 1 week or 4 weeks after operation, the volume of hematoma and hematoma + edema in the nicardipine group decreased more significantly than that in the urapidil group, and there was statistical significance; in terms of CSS score , the CSS scores of the nicardipine group were significantly lower than those of the urapidil group at the 4th and 12th weeks (11.
2±6.
1 vs 14.
5±5.
8 and 4.
5±2.
3 vs 6.
8±3.
2, respectively), and the difference was statistically significant
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Overall, both groups were effective in controlling blood pressure after hypertensive intracerebral hemorrhage, but nicardipine still had considerable advantages in terms of comprehensive neurological recovery and CSS score
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At the same time, nicardipine is convenient to use, and there is no need for additional administration before intravenous infusion, which also brings more convenience to clinical work
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As a dihydropyridine calcium channel blocker, nicardipine can effectively relieve the local brain edema caused by surgical trauma and vasoactive substance exudation around the hematoma around the postoperative surgical area, and protect the brain tissue and vascular endothelial function , significantly improved prognosis
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The expected target can be achieved within 2 hours after nicardipine administration, with stable blood pressure and safe use
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During the course of the medication, the patient tolerated it well, and the risk of discontinuation was small
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The results of the interactive time medical community showed that the volume of hematoma + edema in the nicardipine group at 1 week and 4 weeks after the operation was significantly smaller than that in the urapidil group, and the postoperative CSS score of the nicardipine group was lower than that of the urapidil group
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Please combine pharmacological effects and pathophysiology for a brief analysis of this
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▌Calcium antagonist (CCB) properties endow nicardipine with stronger protection of brain tissue It can also effectively relieve the local cerebral edema caused by surgical trauma and the exudation of vasoactive substances around the hematoma around the operation area, and protect the brain tissue and cerebral vascular endothelial function, thereby significantly improving the prognosis.

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The results of this clinical observation show that nicardipine has the following characteristics: (1) The effect is fast and the curative effect is high
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While reducing systolic blood pressure, diastolic blood pressure was also significantly reduced
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(2) The antihypertensive effect is stable and widely used
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After the medication, the blood pressure of the patients decreased relatively steadily, and there was no sudden drop or sudden rebound
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(3) The administration concentration is low and the use is convenient
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Appropriate adjustment of the administration rate during treatment can control blood pressure to a satisfactory level
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(4) It is safe to use, the medication does not need to be closely monitored, and the curative effect can be predicted
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▌Improve circulation and relieve spasm, Nicardipine is more suitable for blood pressure management after cerebral hemorrhage It is easy to rupture and bleed in other parts, and it is easy to form a hematoma after hemorrhage, which further squeezes the brain tissue and causes microcirculation disturbance, which causes ischemia and hypoxia around the hematoma, and then forms cerebral edema
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Cerebral edema, as an important event in secondary damage of hypertensive intracerebral hemorrhage, usually goes through 3 stages: ultra-early (within 6 hours) cerebral edema due to hydrostatic pressure and blood clot retraction; stage 2 (within 2 days) ) brain edema results from the coagulation cascade and thrombin action; brain edema in stage 3 (3 days and above) is the result of erythrocyte lysis and hemoglobin release
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After the onset of the disease, measures such as clearing the hematoma and controlling blood pressure and intracranial pressure have become the main methods to control the disease
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Nicardipine lowers blood pressure while improving cerebral circulation, cerebral vasospasm, and increasing local blood flow without increasing intracranial pressure
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In the medical community, please discuss the advantages of nicardipine in treating hypertensive emergencies with brain injury based on your clinical medication experience
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▌Blood pressure while ensuring perfusion, the guidelines recommend nicardipine Gao Peng for hypertensive emergencies/encephalopathy: Nicardipine mainly targets L-type calcium ion channels, which can reduce the permeability of the blood-brain barrier and inhibit the calcium in the vascular endothelium of the brain.
The ions enter cells, thereby effectively dilating cerebral blood vessels and reducing intracranial pressure
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Nicardipine significantly reduced cerebral perfusion pressure from baseline levels without increasing cerebral edema and cerebral hemorrhage
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While reducing intracranial pressure, it ensures adequate oxygen supply to brain tissue and prevents the progression of the disease to cerebral edema
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When blood pressure rises suddenly (more than 40% of MAP/about 50 mmHg), the Bayliss effect is further affected, predisposing to hyperperfusion, leading to severe cerebral edema and hemorrhage, while nicardipine increases blood supply to the brain and may help Left shift of the Bayliss curve in hypertensive emergencies
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When nicardipine acts on spasm blood vessels and small arteries, its diameter expansion is more obvious
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Compared with labetalol, nicardipine has more stable blood pressure control, less dose changes, and less need to add other antihypertensive drugs
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Guidelines recommend nicardipine as a first-line antihypertensive drug for hypertensive emergencies/hypertensive encephalopathy
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▌Lower blood pressure while protecting the endothelium, nicardipine can effectively reduce the risk of rebleeding Zhang Chunlei: Patients with hypertensive emergency combined with brain injury need to ensure cerebral perfusion while reducing blood pressure to minimize the impact on intracranial pressure.
Taking into account the reduction of cerebral edema and intracranial pressure, patients with cerebral hemorrhage should avoid re-bleeding on the basis of ensuring cerebral tissue perfusion.
When controlling blood pressure, intracranial pressure and cerebral perfusion pressure must be considered to avoid secondary cerebral ischemia
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Nicardipine is a first-line blood pressure management drug recommended by domestic and foreign guidelines.
Research at home and abroad has confirmed that it has the following advantages: 1.
Reduce the risk of rebleeding: it can effectively act on cerebrovascular endothelial cells, reduce the permeability of the cerebrovascular barrier, and quickly 2.
Ensure cerebral perfusion: increase cerebral blood flow, enhance automatic regulation of cerebral blood flow, maintain perfusion, significantly inhibit cerebral vasospasm, and improve prognosis; 3.
Avoid excessive blood pressure: It does not increase the risk of cerebral hemorrhage and cerebral edema, ensures sufficient oxygen supply to the brain tissue, and curbs the progress of cerebral hemorrhage
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In conclusion, nicardipine is a fast, stable and safe antihypertensive drug while protecting brain tissue
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References: [1] Yu Zhaoang, Cui Yuanxiao, Tian Min, et al.
Research progress of minimally invasive surgery in the treatment of hypertensive cerebral hemorrhage [J].
Shandong Medicine, 2010, 50(001):112-113.
[2] Yang Zhixiong, Yu Dongping, Yang Shiguang.
Comparison of the efficacy of nicardipine and urapidil on postoperative hypertensive cerebral hemorrhage[J].
Chinese Journal of Practical Neurological Diseases,2010,13(05):6-8.
[3] Williams B, Mancia G, Spiering W, et al.
2018 ESC/ESH Guidelines for the management of arterial hypertension [published correction appears in Eur Heart J.
2019 Feb 1;40(5):475].
Eur Heart J.
2018;39 (33):3021-3104.
[4] Powers WJ, Rabinstein AA, Ackerson T, et al.
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationStroke.
2019;50(12):e344-e418.
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