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ARTICLES: P. K. Lindenauer, M. C. Mathew, T. S. Ntuli, P. S. Pekow, J. Fitzgerald, and E. M. Benjamin Use of antihypertensive agents in the management of patients with acute ischemic stroke Neurology 2004; 63: 318-323 [Abstract] [Full text] [PDF]

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Use of antihypertensive agents in the management of patients with acute ischemic stroke

Timothy J Ingall   (31 August 2004)

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Peter K Lindenauer, M. C. Mathew, T. S. Ntuli, P. S. Pekow , J. Fitzgerald, E. M. Benjamin   (31 August 2004)

Use of antihypertensive agents in the management of patients with acute ischemic stroke 31 August 2004
Timothy J Ingall, Mayo Clinic Scottsdale Department of Neurology, Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale AZ 85259 Send Correspondence to journal: Re: Use of antihypertensive agents in the management of patients with acute ischemic stroke tingall{at}mayo.edu Timothy J Ingall	Lindenauer et al presented interesting information regarding the pattern of use of oral antihypertensive drugs in acute stroke patients in a community hospital. However, they didn't provide any information on one of the the most critical questions regarding the management of hypertension in acute stroke patients, which is whether treatment with intravenous medication was used to lower blood pressure acutely. Most physicians would not question the use of oral antihypertensive medications in acute stroke patients, but there has been significant discussion and debate regarding the safety and efficacy of lowering high blood pressure acutely in acute stroke patients. It would be helpful to know whether the authors have information on how many patients received intravenous medication/s to lower blood pressure acutely. In addition, the authors could indicate what medications were used and if there were any adverse effects.
Reply to Ingall 31 August 2004
Peter K Lindenauer, Baystate Medical Center and Tufts University School of Medicine 759 Chestnut Street, Springfield MA 01199, M. C. Mathew, T. S. Ntuli, P. S. Pekow , J. Fitzgerald, E. M. Benjamin Send Correspondence to journal: Re: Reply to Ingall Peter.Lindenauer{at}bhs.org Peter K Lindenauer, et al.	We thank Dr. Ingall for his comments and inquiries. As reported in Table 3, 11 patients were treated with direct acting vasodilators during the first few days of their hospitalization, principally sodium nitroprusside and hydralazine. Another three received labetalol. While the use of such agents leaves little doubt as to the intention of the treating physician, Dr Ingalls’ statement regarding the unquestioned use of oral antihypertensive agents underscores the confusion surrounding use of these medications in the acute setting and the variation in attitudes and practices concerning hemodynamic management of patients with ischemic stroke. It would be a mistake to focus on the intravenous agents because these medications make up only a small fraction of the antihypertensive agents administered to stroke patients. In addition, oral medications are as likely to lower blood pressure; orally administered nicardipine and captopril are two agents specifically described in current Stroke Council Guidelines. [1] It can also be argued that the intravenously administered medications are better for those few patients who require antihypertensive treatment because they offer a degree of control and predictability unmatched by oral and sublingual preparations. Because prior studies [2] have suggested that treatment with antihypertensive agents is detrimental to functional outcomes, and since current guidelines recommend against such treatment, we chose to focus our analysis on quality of care by measuring adherence to these recommendations. Considering prior studies, it is worth noting that 1 in 20 patients developed frank hypotension on a day they received treatment with antihypertensive agents. Perhaps we ought to question the routine use of these orally administered agents. References 1. Adams HP, Jr., Adams RJ, Brott T, et al. Guidelines for the early management of patients with acute ischemic stroke. A statement from the Stroke Council of the American Stroke Association. Stroke 2003;34:1056-1083. 2. Oliveira-Filho J, Silva SCS, Trabuco CC, Pedreira BB, Sousa EU, Bacellar A. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology, 2003;61:1047-1051.