Hypertension during the acute phase of stroke - Management of

Publication: 22/11/2018  --
Last review: 01/01/1900  
Next review: 22/11/2021  
Clinical Guideline
CURRENT 
ID: 5789 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Management of hypertension during the acute phase of stroke

This is a guide to the management of hypertension during the acute phase of stroke and is particularly relevant for use in the Emergency Department(ED) and the Hyper Acute Stroke Unit (HASU). This guide is to be used alongside existing guidelines and protocols for the management of stroke and will concentrate on the medications to be used.

The guideline will include the management of the following stroke patients:

  • Ischaemic stroke patients where thrombolysis is not indicated.
  • Ischaemic stroke patients where thrombolysis is indicated.
  • Stroke patients with an intra-cerebral haemorrhage (ICH).

Healthcare professionals involved in the prescribing, monitoring and administration of medicines included in this document must adhere to the LTHT medicine code

Uncontrolled hypertension is defined as TWO systolic blood pressure (sBP) readings >140mmHg, taken 5-10 minutes apart. This document will focus on the management of patients with sBP >185 and/or diastolic blood pressure (dBP) of >110 mmHg.

Labetalol IV bolus and/or IV infusion is the first line agent for the management of hypertension in stroke patients.

Alternatives to IV labetalol include IV glyceryl trinitrate infusion, IV nicardipine, sub-lingual lisinopril, glyceryl trinitrate patch and other anti-hypertensive medication given down an enteral tube.

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Intravenous Labetalol

Labetalol lowers blood pressure primarily by blocking peripheral arteriolar alpha-adrenoceptors thereby reducing peripheral resistance and by concurrent beta-receptor blockade, protects the heart from reflex sympathetic drive which would occur.

Contra-indications include (refer to leedsformulary):

  • Cardiogenic shock.
  • Uncontrolled, incipient or digitalis refractory heart failure.
  • Sick sinus syndrome (including sino-atrial block).
  • Second or third degree heart block.
  • Prinzmetal’s angina.
  • History of wheezing/asthma.
  • Untreated phaeochromocytoma.
  • Metabolic acidosis.
  • Bradycardia (<50bpm) - check if the patient has a permanent pacemaker in situ.
  • Severe peripheral circulatory disturbances.
  • Hypersensitivity to labetalol.

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Labetalol IV Bolus

Labetalol is available in 100mg in 20ml ampoules and must be diluted to a 1mg/ml final concentration before administered as a bolus dose. For example 10mg/2ml can be further diluted with 8ml of sodium chloride to give a 10mg/10ml solution.

First bolus dose (administered over 2minutes) = 10mg and monitor BP every 5 minutes and if BP remains high on two consecutive readings give a second bolus dose.

Second bolus dose (administered over 2 minutes) = 20mg and if BP is not lowered then commence an IV labetalol infusion.

Labetalol 200mg/200mL IV Infusion

Require:
2 x Labetalol 100mg/20mL ampoules .
1 x Sodium chloride 0.9% 250mL infusion bag.

Preparation:

  • Withdraw 90mL of from a 250mL Sodium chloride 0.9% infusion bag and discard the 90mL.
  • Add 200mg/40mL (2x ampoules) of labetalol to the Sodium chloride 0.9% infusion bag to give a solution of 200mg labetalol in 200mL Sodium chloride 0.9% (1mg/1mL).

Infusion:

Using an infusion pump commence the infusion at the prescribed rate and titrate according to the prescription.

The infusion of the above concentration is usually started at 120mL/hour (2mL/min) and the dose is adjusted according to BP using 120mL/hour (2mL/min) increments every 5 minutes until a maximum of 480mL/hour (8mL/min) is reached.

If a total dose of 300mg labetalol has been administered in 24 hours then the patient must be reviewed by the Stroke Consultant or Specialist Registrar on duty.

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Patients for thrombolysis

Thrombolysis within license requires a systolic blood pressure (sBP) <185mmHg and a diastolic blood pressure (dBP) <110 mmHg. In the flow diagram below this paired threshold is represented as ‘BP <185/ 110’ (Figure 1).

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Ischaemic stroke patients not for thrombolysis


Patients in this group who are extremely hypertensive may benefit from a gradual reduction of their BP.  Elevated BP usually settles without intervention.  BP correction should be achieved over 24 hours.  Anecdotally, a rapid BP drop can be associated with a clinical deterioration secondary to hypoperfusion.  If hypertensive encephalopathy is suspected BP management will be agreed with the Consultant otherwise the following pathway can be used (Figure 2).

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Patients with intracerebral haemorrhage within 6 hours of symptom onset


For patients with haemorrhagic stroke where ICP elevation is likely then consider HDU monitoring on an individual basis.  All other haemorrhagic stroke patients with systolic BP > 150 mmHg for 3 consecutive readings 5 mins apart please follow the algorithm below.

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Alternatives to IV labetalol

Note: Do not use the IV admin documentation WPG676

  • Glyceryl trinitrate(GTN) intravenous infusion

This is usually the second line agent if labetalol is contra-indicated. Caution in ICH where patient may already have a headache, this may exacerbate this symptom. Glyceryl trinitrate is a continuous infusion and is prepared as follows:

Contra-indications include (refer to e BNF and/or netFORMULARY):

  • Known hypersensitivity to nitrates
  • Severe anaemia
  • Severe cerebral haemorrhage
  • Head trauma
  • Uncorrected hypovolaemia and hypotensive shock
  • Arterial hypoxaemia and angina caused by hypertrophic obstructive cardiomyopathy constrictive pericarditis
  • Pericardial tamponade
  • Toxic pulmonary oedema
  • Confirm if patient has taken any nitrate containing medication in the last 24 hours, as this may affect the dose  of Gylceryl Trinitrate infuison
  • Sildenafil potentiates the hypotensive effects of nitrates and its co-administration with Glyceryl Trinitrate is contraindicated. Confirm if the patient has taken sildenafil or like medicines in the past 24 hours.
  • Glyceryl Trinitrate should be administered with caution and under continuous monitoring to patients with acute left-sided heart failure or acute myocardial infarction and only when the systolic blood pressure exceeds 90 mm Hg

 

Require:

1x ready diluted 50mg in 50ml glyceryl trinitrate vial.

Preparation:

Draw the 50mg in 50ml glyceryl trinitrate vial into a 50ml IV syringe.

Infusion:

Place the syringe in a suitable infusion pump and set an initial rate at 300micrograms/hour (0.3ml/hour) unless otherwise instructed by medical staff.

Administration:

  • Adjust the infusion rate according to the prescription. Rates can usually be increased by increments of 0.5 ml(500microgrammes) per hour. Up to maximum of 10mls (10mgs) per hour.
  • Re-check observations and symptoms every 15 minutes after starting the infusion and after every infusion rate change.
  • If the infusion rate is unchanged then re-check the observations and symptoms every 30 minutes for the first hour and then check every hour thereafter.
  • Check the residual volume remaining in the syringe at least every hour.

Inform medical staff if the systolic blood pressure drops below 160mmHg.

  •  
    • A glyceryl trinitrate 5mg or 10mg patch can be applied for 12 hours each day as alternative to a glyceryl trinitrate infusion.

Intravenous Nicardipine infusion

This is a calcium channel blocker and is used if the labetalol and/or glyceryl trinitrate infusions are contra-indicated or are not clinically appropriate.

Initial dose: Treatment should start with the continuous administration of nicardipine at a rate of 3 mg/hour for 15 minutes. Rates can be increased by increments of 0.5 or 1 mg every 15 minutes. The infusion rate should not exceed 15 mg/hour.

Maintenance dose: When the target pressure is reached, the dose should be reduced progressively, usually to between 2 and 4 mg/h, to maintain the therapeutic efficacy.
.
Older patients/renal impairment/hepatic impairment
Clinical studies of nicardipine did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.
Elderly patients may be more sensitive to nicardipine effects because of impaired renal and/or hepatic function. It is recommended to provide a continuous infusion of nicardipine starting at the dose of 1 mg/h, depending on the blood pressure and clinical situation. After 30 minutes, depending on the effect observed, the rate should be increased or decreased by increments of 0.5 mg/hour. The rate should not exceed 15 mg/hour.

Contraindications

  • Known hypersensitivity to nicardipine or to any of the excipients Severe aortic stenosis
  • Compensatory hypertension, i.e. in case of an arteriovenous shunt or aortic coarctation
  • Unstable angina
  • Within 8 days after myocardial infarction
  • Patients with rare hereditary problems of fructose intolerance should not take this medicine

Require:

2 x Nicardipine 10mg in 10ml ampoules.
1 x Sodium chloride 0.9% 250mL infusion bag

Preparation:
Withdraw 70mL from a 250mL Sodium chloride 0.9% infusion bag and discard the 70mL. Add 20mg/20ml nicardipine (2x ampoules) to the infusion bag to give an infusion bag containing 20mg nicardipine in 200mL sodium chloride 0.9% (concentration of 1mg/10ml)

Infusion:

Place the syringe in a suitable infusion pump and set an initial rate as per the prescription.

Administration:

  • If systolic BP>185mmHg start nicardipine infusion at a rate of 3-5mg/hour (1-5mg/hour in older patients) for 15 minutes.
  • Then increase by 500micrograms-1mg every 15 minutes (every 30minutes in older patients), according to response to a maximum of 15mg/hour.
  • Once target BP has been reached gradually reduce the infusion rate by 500 microgrammes - 1mg to a usual maintenance rate of 3mg/hour.

Sublingual lisinopril

Place a 5mg tablet under the patient’s tongue and allow the tablet to disperse. This can be used as an addition to inventions discussed in this guidance or to allow administration of an angiotensin converting enzyme inhibitor to patients who are nil by mouth without an enteral tube.

Early insertion of an enteral tube

An early insertion of an enteral tube is an option to allow other anti-hypertensives to administered enterally in patients who are nil by mouth. Please discuss with Consultant whether it is safe to insert an ngt within first 24hrs post thrombolysis.Please seek advice from pharmacy regarding administration of individual anti-hypertensives down enteral tubes on an individual basis.

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Management of hypertension after the acute phase of stroke

Generally treatment should be initiated as per current UK national guidelines to achieve a systolic blood pressure of <130mmHg (unless the patient has severe bilateral carotid stenosis in which case a target of 140 to 150mmHg may be more appropriate).

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Provenance

Record: 5789
Objective:
Clinical condition:

Stroke

Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

The Royal College of Physicians. National clinical guideline for stroke 2016(5th edition).
Available: https://www.rcplondon.ac.uk/guidelines-policy/stroke-guidelines
Accessed: 01/03/2018

Limaye S et al. The Leeds Teaching Hospitals NHS Trust stroke management guideline 2014.
Available: detail.aspx?ID=1165
Accessed: 01/03/2018

Wanklyn P et al. The Leeds Teaching Hospitals NHS Trust thrombolysis for acute ischaemic stroke guideline 2012.
Available: detail.aspx?ID=1117
Accessed: 01/03/2018

National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Clinical Guideline 127 (2011).
Available:
http://nice.org.uk/guidance/cg127
Accessed: 01/03/2018Whelton PK et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 7/5/18
Available: http://www.onlinejacc.org/content/71/19/e127?_ga=2.150404159.867835749.1532700779-1281564237.1532700779 Accessed 01/06/2018
Jauch EC et al. Guidelines for the early management of patients with
acute ischemic stroke a guideline for healthcare professionals from the American HeartAssociation/American Stroke Association. Stroke. 2013;44:870-947.

Martin-Schild, S et al. Aggressive blood pressure lowering treatment before intravenous tissue plasminogen activator therapy in acute ischaemic stroke. JAMA Neurology 2008; 65(9): 1174-1178.

Xi L et al. A comparison of nicardipine and labetalol for acute hypertension management following stroke. Neurocrit Care 2008;9: 167-176.

Delcourt C, Huang Y, Wang J, et al. The second (main) phase of an open, randomised, multicentre study to investigate the effectiveness of an INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT2). Int J Stroke 2010;5:110-116

Anderson C et al. Enhanced control of hypertension and thrombolysis stroke study(ENCHANTED). Study protocol 2012(Ongoing phase III clinical trial estimated to complete 2019). Study protocol on file in Leeds Teaching Hospitals NHS Trust, Pharmacy Clinical Trials Department.
Harrington C. Managing hypertension in patients with stroke. Are you prepared for labetalol infusion? Crit Care Nurse 2003;23(3): 30-38.
Potter J et al. Controlling hypertension and hypotension immediately post stroke (CHHIPS)--a randomised controlled trial. Health Technol Assess 2009;13(9):1-73

University College Hospitals Foundation NHS Trust. Management of blood pressure in acute stroke 2012 (version 3.3). Obtained by personal communication and permission from University College Hospitals Foundation NHS Trust.

Focus Pharmaceuticals Ltd. Summary of product characteristics(SPC) for labetalol 5mg/ml injection.
Available: http://www.medicines.org.uk/emc/
Accessed: 01/03/2018

Amdipharm Mercury Company Ltd. Summary of product characteristics(SPC) for nicardipine 10mg/10ml injection.
Available: http://www.medicines.org.uk/emc/
Accessed: 01/03/2018

Hameln Pharmaceuticals Ltd. Summary of product characteristics(SPC) for glyceryl trinitrate 50mg/50ml injection.
Available: http://www.medicines.org.uk/emc/
Accessed: 01/03/2018

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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