Hypertension during the Acute Phase of Stroke - Management of

Publication: 22/11/2018  
Next review: 11/02/2025  
Clinical Guideline
CURRENT 
ID: 5789 
Supported by: Stroke Medicine MDT
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

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

This guideline is for Stroke patients only and NOT for patients with other hypertensive related conditions.

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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Ischaemic Stroke Patients for Thrombolysis and/or Thrombectomy

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).

This guideline is for Stroke patients only and NOT for patients with other hypertensive related conditions.


Figure 1 - Patients for thrombolysis and/or thrombectomy

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Ischaemic stroke patients NOT for thrombolysis and/or thrombectomy

This guideline is for Stroke patients only and NOT for patients with other hypertensive related conditions.

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).


Figure 2 - Ischaemic Stroke Patients not for thrombolysis and/or thrombectomy

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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.

This guideline is for Stroke patients only and NOT for patients with other hypertensive related conditions.


Figure 3 - Patients with intracerebal haemorrhage within 6 hours of symptom onset

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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.

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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Alternatives to Intravenous Labetalol

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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). Caution should also be exercised in patients ≥80 years with frailty or multi-morbidity where the initial target should be <150/90 mmHg (clinic blood pressure); more intensified treatment can be applied on an individualised basis.

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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: http://nww.lhp.leedsth.nhs.uk/common/guidelines/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: http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=1117
Accessed: 01/03/2018

Hypertension in adults: diagnosis and management. NICE guideline [NG136]
Published: 28 August 2019.
Available: Overview | Hypertension in adults: diagnosis and management | Guidance | NICE
Accessed: 30/12/2021

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.
Available: http://www.onlinejacc.org/content/71/19/e127?_ga=2.150404159.867835749.1532700779-1281564237.1532700779
Accessed: 07/05/2018

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, 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. Stroke. 2019;50:e344–418.These are the current recommendations for treatment of AIS patients

Available: https://pubmed.ncbi.nlm.nih.gov/31662037
Accessed: 30/12/2021

European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhageEur Stroke J May 11, 2021 pp. XLVIII–LXXXIX
Available: https://doi.org/10.1177%2F23969873211012133
Accessed: 30/12/2021

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 2.0

Related information

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