The first "Shanghai Expert Recommendations for Blood Pressure Management of Inpatients with Ischemic Stroke" is released today!

Clinical studies have shown that nearly 70% of patients with acute ischemic stroke (AIS) have elevated blood pressure, but early intensive antihypertensive therapy cannot improve the clinical prognosis of patients
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Accumulated evidence shows that individual blood pressure variability (BPV) in the acute phase of AIS is closely related to the patient's long-term functional recovery, hemorrhage transformation and death, and is a risk factor independent of the average blood pressure
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Therefore, reducing BPV has equally important clinical significance for blood pressure control in the acute phase of AIS patients and blood pressure management for secondary prevention
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At present, domestic and foreign guidelines have standardized the blood pressure management in primary prevention, acute phase treatment and secondary prevention of ischemic stroke.
However, the domestic and foreign guidelines have not paid enough attention to BPV, and there are operational quality control blind spots.

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Hospitalization of patients with ischemic stroke is the best time to achieve good blood pressure control
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Therefore, the Shanghai Stroke Society led by Professor Dong Qiang from Huashan Hospital Affiliated to Fudan University drafted the "Shanghai Expert Recommendations for the Management of Blood Pressure Variability in Inpatients with Ischemic Stroke" (hereinafter referred to as "Expert Recommendations"), The Pan-Yangtze River Delta Section Director Sharon·Jiangsu Station announced that the main author of the expert’s recommendations at the meeting, Professor Zhao Yuwu from the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University, gave a report on the main points of the expert’s recommendations
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Experts suggest the release ceremony.
Professor Zhao Yuwu interpreted the expert's suggestions on BPV classification and assessment methods.
Human blood pressure has complex spontaneous fluctuations within 24 hours, and this kind of fluctuation is BPV
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There are many classification methods for BPV, which can be divided into physiological, pathological and drug-induced mutations according to the cause; the classification of pathological BPV is shown in Table 1, and the classification of blood pressure monitoring time is shown in Table 2: Table 1 Classification of pathological BPV Table 2 The clinical evaluation methods of BPV classification according to the duration of blood pressure monitoring include office blood pressure, family self-tested blood pressure, and 24h ambulatory blood pressure monitoring
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At present, the blood pressure variability level calculated by ambulatory blood pressure monitoring as the result of short-term BPV has been widely used clinically
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The "2019 Asian Ambulatory Blood Pressure Monitoring HOPE Expert Consensus" pointed out that ambulatory blood pressure monitoring is currently the only method to assess 24h blood pressure and BPV
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Recommendation 1➤ Ambulatory blood pressure monitoring is the preferred method to assess 24h blood pressure and BPV
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➤ All patients with ischemic stroke (regardless of hospitalization or outpatient follow-up) should be regularly monitored for ambulatory blood pressure to rule out white coat hypertension and diagnose concealed hypertension
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➤ Determine whether there is pathological BPV and its types, and guide the blood pressure management of patients with ischemic stroke
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BPV and Acute Ischemic Stroke The current clinical studies on the effects of acute ischemic stroke BPV on the prognosis are mainly focused on short-term BPV and mid-term BPV
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1.
Acute hypertension after ischemic stroke Acute hypertension is common in patients with AIS and acute hemorrhagic stroke (Figure 1), and most patients have their blood pressure drop spontaneously within 24 hours
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Many studies have shown that BPV is an important predictor of poor clinical prognosis in patients with AIS and should be paid attention to
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Figure 1 Acute hypertension is common in stroke patients.
Recommendation 2➤BPV is an independent risk factor for ischemic stroke and poor prognosis.
All patients with ischemic stroke and hypertension should be evaluated for BPV during hospitalization.
And the identification of pathological types
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2.
The effect of BPV on the prognosis of patients with non-vascular recanalization of AIS Most studies believe that elevated BPV has an adverse effect on the prognosis of stroke (Table 3): Table 3 Relevant research recommendations on the impact of BPV on the prognosis of patients with non-vascular recanalization of AIS 3➤Hospitalization The assessment of BPV and the identification of pathological types should be carried out within 24 to 72 hours to guide the decision-making of antihypertensive treatment during hospitalization
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➤The timing of initiation of antihypertensive therapy and the target value for antihypertensive are implemented in accordance with the principles in the "Chinese Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke 2018"
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3.
The effect of BPV on the prognosis of patients with thrombolysis/removal of thrombosis after AIS.
BPV can increase intracranial pressure, aggravate cerebral edema, or cause vasospasm, cause insufficient cerebral perfusion pressure, and aggravate cerebral ischemia or collateral vessel occlusion.
Affects the recovery of neurological function in patients with AIS thrombolysis/thrombolysis (Table 4): Table 4 The influence of BPV on the prognosis of patients with thrombolysis/thrombolysis after AIS Relevant research recommendations 4➤For patients with acute ischemic stroke vascular recanalization , BPV assessment and pathological type identification under ambulatory blood pressure monitoring should be carried out as soon as possible
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➤Different blood pressure measurement methods and frequency should be selected according to the condition of the disease.
BPV assessment and pathological type identification should be carried out within 24 to 72 hours of hospitalization to guide the decision-making of antihypertensive treatment during hospitalization
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BPV and secondary prevention of ischemic stroke BPV is an independent risk factor for target organ damage such as stroke, cardiovascular events, mortality, carotid atherosclerosis, etc.
Reducing BPV is an important part of long-term blood pressure management for all hypertensive patients One of the goals
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1.
Nocturnal hypertension Nocturnal hypertension is an independent risk factor for cardiovascular and cerebrovascular events, especially stroke; compared with daytime blood pressure, nocturnal blood pressure is more closely related to the risk of death from all causes and cardiovascular and cerebrovascular diseases
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2.
The morning peak of blood pressure and the morning peak of blood pressure under the physiological state of early morning hypertension are the manifestation of normal circadian rhythm.
Excessive increase will cause serious harm and may be the main reason for the significant increase in the incidence of cardiovascular and cerebrovascular events in the early morning.
Hypertension also has important predictive value for ischemic stroke
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3.
Circadian rhythm of blood pressure and short-term variation of parameters Non-dipper and anti-dipper blood pressure rhythms are related to target organ damage and increased risk of death from cardiovascular and cerebrovascular diseases
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Ultra-dipper blood pressure is associated with many poor prognosis, especially cerebrovascular events
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Recommendation 5➤ Reducing BPV in patients with hypertension is one of the important therapeutic goals in the secondary prevention of ischemic stroke
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➤It is recommended that all patients with ischemic stroke and high blood pressure should undergo ambulatory blood pressure monitoring before discharge to evaluate the effect of antihypertensive treatment during hospitalization and to guide good blood pressure management during secondary prevention after discharge
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The main measures to reduce BPV in hypertensive patients The reduction of BPV in hypertensive patients can be analyzed from two perspectives: drug therapy and blood pressure monitoring and evaluation: 1.
From the perspective of drug therapy, the use of long-acting antihypertensive drugs and combination drugs is advocated, especially the effect The combination of two or more drugs with incomplete mechanisms can significantly enhance the effect of stabilizing blood pressure
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2.
From the perspective of blood pressure monitoring and evaluation, the compliance rate of using ambulatory blood pressure monitoring to guide blood pressure treatment is higher than that of office blood pressure.
It is recommended to adjust the blood pressure plan according to the results of ambulatory blood pressure monitoring; ambulatory blood pressure monitoring can be reviewed every 2 to 3 weeks until blood pressure is controlled Until stable
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Recommendation 6➤ Use long-acting antihypertensive drugs and combination drugs, and adjust the blood pressure reduction program according to the results of ambulatory blood pressure monitoring to reduce the BPV of patients with hypertension and achieve the goal of good blood pressure control
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Application of new antihypertensive drugs in patients with AIS.
Traditional antihypertensive therapy focuses on inhibiting the mechanism of blood pressure, ignoring the new target of enhancing the mechanism of blood pressure-natriuretic peptide system (NPs).
Natriuretic peptides reflect changes in blood pressure within 24 hours.
The endogenous hormones can be used as a new target for antihypertensive therapy
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The new antihypertensive drug sacubitril and valsartan is the first angiotensin receptor enkephalinase inhibitor (ARNI) drug.
It is a single co-crystal composed of sacubitril and valsartan in a ratio of 1:1 Drugs, to achieve multi-channel blood pressure reduction (Figure 2)
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Figure 2 The antihypertensive mechanism of sacubitril and valsartan sacubitril is a prodrug.
After entering the body, it is metabolized by esterase into the active product LBQ657, which inhibits enkephalinase activity
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Enkephalinase has a variety of substrates, including natriuretic peptide and angiotensin II (Ang II)
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Inhibition of enkephalinase can increase the level of natriuretic peptides in the body that have antihypertensive and organ protection effects
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Valsartan can effectively inhibit the angiotensin Ⅱ type 1 receptor (AT1R), play a role in lowering blood pressure and organ protection
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At the same time, the eutectic structure can make the absorption and elimination rates of sacubitril and valsartan close, ensuring the synchronization and consistency of the efficacy of the two
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1.
Sacubitril and valsartan has a 24-hour stable and strong antihypertensive effect.
At present, many high-quality clinical studies have fully proved that sacubitril and valsartan are stable, safe and effective in the treatment of hypertension.

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Table 5 Sacubitril and Valsartan has sufficient antihypertensive effects for patients with severe hypertension, patients with poorly controlled single-drug hypertension, and patients with special types of hypertension (such as: elderly hypertension patients, salt-sensitive hypertension patients ), also has a good blood pressure reduction effect
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Sacubitril and valsartan are more effective in reducing 24h arterial systolic blood pressure, pulse pressure and night blood pressure
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The PARAMETER study (Figure 3) showed that compared with the olmesartan group, the central aortic systolic blood pressure (CASP) and central arterial pulse pressure (CAPP) of the sacubitril and valsartan group decreased significantly and were more effective at 12 weeks of treatment.
Lower night blood pressure at 12 and 52 weeks
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Figure 3 Results of the PARAMETER study 2.
Sacubitril and Valsartan has a target organ protective effect.
"Cerebral heart syndrome" is one of the most serious acute complications of AIS patients (Figure 4), which greatly increases the poor prognosis of AIS patients
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In addition to the overall antihypertensive effect, sacubitril and valsartan have excellent protective effects on target organs such as heart, kidney, and blood vessels, and are particularly suitable for application in patients with AIS
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Figure 4 The incidence of common complications after AIS.
Ischemic stroke is often accompanied by arteriosclerotic chronic diseases such as diabetes, chronic kidney disease, and coronary heart disease.
These diseases have mutually causal effects
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Clinical studies have shown that sacubitril and valsartan also have the effects of improving insulin sensitivity, improving metabolic disorders and lowering uric acid, which is suitable for patients with hypertension, obesity and diabetes
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Recommendation 7➤Sakurabatril and Valsartan has the effects of multi-target organ protection and improvement of metabolic disorders
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It also has unique advantages in reducing nocturnal hypertension and reducing BPV in Asian patients .

The use of sacubitril and valsartan is recommended in the secondary prevention of patients with ischemic stroke and hypertension
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➤Sacubatril and Valsartan has a unique cardioprotective effect.
AIS patients are usually accompanied by various cardiac complications
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It is recommended to use sacubitril and valsartan in patients with AIS with cardiac dysfunction and other cardiac complications, as well as AIS patients with antihypertensive treatment
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In short, the "Expert Recommendations" is the first guideline that focuses on the blood pressure variability of hospitalized patients with ischemic stroke, provides detailed recommendations for the blood pressure management of hospitalized patients with ischemic stroke, and is helpful for improving China's ischemic brain The prognosis of stroke patients is of great significance
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Expert profile Professor Dong Qiang, Shanghai Leading Talent, Shanghai Top Ten Public Health Worker, Director of Neurology Department, Huashan Hospital, Fudan University, Deputy Director, National Center for Neurological Diseases (Huashan), Deputy Director, Chinese Medical Association Neurology Branch, Vice Chairman, Chinese Stroke Society Professor Zhao Yuwu, Chairman of the Neurology Committee of the Shanghai Medical Association, Chairman of the Neurologist Branch of the Shanghai Medical Association, Director of the Shanghai Neurological Diseases Clinical Medicine Center, and Director of the Shanghai Neurology Quality Control Center, Executive Vice President of the Shanghai Stroke Society Doctor of Neurology, Chief Physician/Professor, Doctoral Supervisor, Director of Neurology Department, Sixth People's Hospital, Shanghai Jiaotong University Member of the Society for Critical Cerebrovascular Diseases, Vice Chairman of the Neurology Branch of the Shanghai Medical Association, Vice Chairman of the Neurology Branch of the Shanghai Medical Doctor Association, Vice Chairman of the Chronic Disease Management Committee of the Shanghai Medical Association, and Deputy Secretary-General of the Shanghai Stroke Society
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The project leader has won 5 National Natural Science Foundation of China, and the first/corresponding author has published more than 100 papers
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The first completer won 4 scientific and technological achievement awards
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References: 1.
Shanghai expert advice on blood pressure management for hospitalized patients with ischemic stroke.