Οξύ ισχαιμικό και αιμορραγικό

Δύσκολα ΜΟΝΑΔΕΣ ΕΝΤΑΤΙΚΗΣ θεραπευόμενη ΘΕΡΑΠΕΙΑΣ - ΚΑΡΔΙΟΛΟΓΙΚΗ υπέρταση: Οξύ ισχαιμικό και αιμορραγικό Δρ., MD, MSc, PhD Καρδιολόγος Ακαδημαϊκός Υπότροφος Ιατρικής Σχολής Παν. Αθηνών Ά Παν. Καρδιολογική Κλινική, Ιπποκράτειο Γ.Ν.Α. Ιδιωτικό Ιατρείο: Θήβα Βουρδουμπά 14 21.02.2019 ΚΑΡΔΙΟΛΟΓΙΚΗ ΝΟΣΗΛΕΥΤΙΚΗ» εγκεφαλικό ΣΤΗΝ ΑΡΤΗΡΙΑΚΗ επεισόδιο. ΣΚΛΗΡΙΑ

ΣΤΗΝ Conflicts ΑΡΤΗΡΙΑΚΗ of interest: ΣΚΛΗΡΙΑ None

Literature

Hypertension and Acute Stroke Blood pressure (BP) elevation above premorbid levels is observed in at least 60% of acute ischemic and hemorrhagic stroke patients, within the first 24h of symptom onset, but often declines without intervention. High BP may be associated with poor stroke outcome. BP management during the acute phase of haemorrhagic and ischaemic stroke remains an area of uncertainty. Appiah KO, et al. Curr Opin Neurol 2018;31:8-13. Appiah KO, et al. Curr Opin Neurol 2018;31:8-13.

Pre-hospital treatment of High BP in Acute Stroke

Ischaemic Stroke: Acute Phase

Cerebral Blood Flow (CBF) Cerebral Autoregulation Acute str ΕΠΙΔΡΑΣΗ ΤΗΣ ΑΝΤΙΥΠΕΡΤΑΣΙΚΗΣ Ischaemic k ΑΓΩΓΗΣ Stroke 60 80 150 Mean arterial pressure (mmhg) Acute Normal

Ischaemic Stroke: Acute Phase The beneficial effects of BP reduction are uncertain in acute ischaemic stroke. A key consideration is whether the patient will receive thrombolysis, because observational studies have reported an increased risk of intracerebral haemorrhage in patients with a markedly elevated BP who received thrombolysis. 1 η Πανεπιστημιακή In patients Καρδιολογική receivingκλινική i.v. thrombolysis, & Ομώνυμο Εργαστήριο, BP should be Ιπποκράτειο lowered and Νοσοκομείο, maintainedμονάδα at <180/105 Υπέρτασης mmhg for at least the first 24 Ιατρική h after Σχολή thrombolysis Ε.Κ.Π.Α. (Class IIa, Level B). Lee M, et al. Stroke 2015;46:1883-1889. Wu W, et al. PLoS One 2016;11:e0144260.

Ischaemic Stroke: Acute Phase The benefit of acute BP lowering in patients with acute ischaemic ΕΝΤΑΤΙΚΗΣ stroke ΘΕΡΑΠΕΙΑΣ who do- ΚΑΡΔΙΟΛΟΓΙΚΗ not receive thrombolysis ΝΟΣΗΛΕΥΤΙΚΗ» is uncertain. prevention ΥΠΕΡΤΑΣΙΚΩΝ of death or dependency. ΑΣΘΕΝΩΝ A meta-analysis suggested that BP lowering early after acute ischaemic stroke had a neutral effect on the In such patients with markedly elevated BP (i.e. SBP 220 or DBP 120 mmhg), clinical judgement should 1 η Πανεπιστημιακή define whether Καρδιολογική to intervene Κλινική & with Ομώνυμο drug therapy. Εργαστήριο, In that Ιπποκράτειο case a reasonable Νοσοκομείο, goal may Μονάδα be toυπέρτασης lower BP by 15%, with close monitoring, Ιατρική Σχολή during Ε.Κ.Π.Α. the first 24 h after stroke onset (Class IIb, Level C). Lee M, et al. Stroke 2015;46:1883-1889. Zhao R, et al. Medicine (Baltimore) 2015;94:e896. Jauch EC, et al. Stroke 2013;44:870-947. Sandset EC, et al. Lancet 2011;377:741-750. Lee M, et al. Stroke 2015;46:1883-1889. Sandset EC, et al. Stroke 2012;43:2108-2114.

Ischaemic Stroke: (Post-)Acute Phase Patients with acute ischaemic stroke and a BP <220/120 mmhg in the first 72 h after stroke do not seem to benefit from the introduction or reintroduction of BP- lowering medication. For stable patients who remain hypertensive ( 140/90 mmhg) >3 days after an acute ischaemic stroke, initiation or reintroduction of BP-lowering medication should be considered. Lee M, et al. Stroke 2015;46:1883-1889. ENOS Trial Investigators. Lancet 2015;385:617-628. Robinson TG, et al. Lancet Neurol 2010;9:767-775.

Ischaemic Stroke: Acute Phase

(Pre-existing) Hypertension and Recent/Previous Stroke Secondary Prevention of Ischaemic Stroke

Haemorrhagic Stroke: Acute Phase

Haemorrhagic Stroke: Acute Phase In acute intracerebral haemorrhage (ICH), an increased BP is common and is associated with a greater risk of worse ΣΤΗΝ prognosis ΑΡΤΗΡΙΑΚΗ for neurological ΣΚΛΗΡΙΑ recovery. haematoma expansion, increased risk of death, and a Rodriguez-Luna D, et al. Eur J Neurol 2013;20:1277-1283. Results from an RCT suggested that immediate BP lowering (within 6 h) to <140/90 mmhg did not show benefit on the primary outcome of disability or death at 3 months, but might reduce haematoma expansion and improve functional recovery, and was generally safe. Sakamoto Y, et al. Stroke 2013;44:1846-1851. Anderson CS, et al. N Engl J Med 2013;368:2355-2365.

Haemorrhagic Stroke: Acute Phase A subsequent RCT, in which SBP was immediately reduced (<4.5 h) from a mean of 200 mmhg to two different target intervals (140 170 vs. 110 139 mmhg), showed that more intensive BP lowering had no benefit on the same primary outcome (death or disability at 3 months) and was associated with more renal adverse events. Thus, we do not recommend treatment to immediately lower BP in patients with acute intracerebral Ιπποκράτειο haemorrhage Νοσοκομείο, (Class III, Level Μονάδα A). Υπέρτασης Qureshi AI, et al. N Engl J Med 2016;375:1033-1043.

Haemorrhagic Stroke: Acute Phase One possible caveat to this recommendation is patients with acute intracerebral haemorrhage and very severe hypertension (SBP 220 mmhg), for whom there are much fewer data. A meta-analysis and secondary outcome data from one RCT have suggested a possible benefit on functional recovery at 3 months, and that acute lowering of SBP to <180 mmhg in these patients might be beneficial. Ιπποκράτειο Thus, careful Νοσοκομείο, lowering of Μονάδα BP viaυπέρτασης i.v. infusion should be considered Ιατρική (ClassΣχολή IIa, Level Ε.Κ.Π.Α. B) in patients with markedly elevated BP (SBP 220 mmhg). Tsivgoulis G, et al. Neurology 2014;83:1523-1529. Anderson CS, et al. N Engl J Med 2013;368:2355-2365.

Haemorrhagic Stroke: Acute Phase

(Pre-existing) Hypertension and Recent/Previous Stroke Secondary Prevention of Haemorrhagic Stroke

Management of BP in OAC pts with Stroke Acenocumarol Rivaroxaban BP Apixaban Dabigatran

Ischaemic Stroke in OAC pts: Post-acute Phase OAC: Oral Anti-Coagulant NIHSS: National Institutes of Health Stroke Severity Scale Start OAC

Haemorrhagic Stroke in OAC pts: Acute Phase being ΣΤΗΝ treated ΑΡΤΗΡΙΑΚΗ with OAC: ΣΚΛΗΡΙΑ - discontinuation ΥΠΕΡΤΑΣΙΚΩΝ of theασθενων drug, In patients with acute IntraCranial Bleeding (ICB) - urgent BP management and - rapid correction of the coagulation status is needed to limit haematoma enlargement.

Haemorrhagic Stroke in OAC pts: Post-acute Phase

Risk factors for bleeding in AF pts on OAC

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