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Blood pressure management in acute stroke: comparison of current guidelines with prescribing patterns
Salmann Kanji1, Céline Corman, Andre G Douen
1Department of Pharmacy, The Ottawa Hospital, University of Ottawa, ON, Canada.
Insights
Management of acute stroke hypertension shows significant variation, with current guidelines having little impact on prescribing patterns. This leads to non-standardized patient care and potential harm due to inappropriate antihypertensive use and inadequate blood pressure monitoring.
Area of Science:
- Neurology
- Cardiology
- Clinical Pharmacy
Background:
- Current acute stroke hypertension management guidelines are primarily based on expert opinion, leading to variability in treatment thresholds and drug selection.
- There is a need to evaluate the adherence to existing guidelines in clinical practice.
Purpose of the Study:
- To investigate the influence of current hypertension management guidelines on prescribing patterns in acute stroke patients.
- To compare the actual management of hypertension in acute stroke at a tertiary care hospital with established guidelines.
Main Methods:
- A retrospective chart review was conducted over six months at The Ottawa Hospital-General Campus.
- Data collected included antihypertensive medication use (type, dose, route), and blood pressure recordings within the first seven days of admission for acute stroke patients.
Main Results:
- Transdermal nitroglycerin paste was the most frequently used agent, often resulting in >15% blood pressure reduction within 24 hours, contrary to recommendations for ischemic stroke.
- Sublingual nifedipine was the second most common agent prescribed, despite safety concerns.
- Mean time to first blood pressure measurement after initiating antihypertensive therapy was prolonged (117 minutes for ischemic, 88 minutes for hemorrhagic stroke).
Conclusions:
- Current guidelines for acute poststroke hypertension management appear to have minimal impact on clinical prescribing practices, resulting in significant practice variations.
- This variability may stem from a lack of robust evidence from randomized controlled trials.
- Inconsistent care, including inappropriate antihypertensive choices and inadequate blood pressure monitoring, poses risks to patient safety.
Objective:
Current recommendations for treating elevated blood pressure (BP) in the acute stroke are based largely on expert opinion and vary with regard to treatment thresholds and choice of antihypertensive agents. In this study we investigate the influence of these recommendations by comparing the management of hypertension in acute stroke at a tertiary care hospital with current guidelines.
Method:
Retrospective chart review of patients admitted with acute stroke at The Ottawa Hospital-General Campus over six consecutive months. The use of antihypertensive medications (type, dose, routes of administration, BP recordings) in the first seven days after admission was noted.
Results:
Transdermal nitroglycerin paste was the most commonly used antihypertensive agent. In contrast to the 15% reduction in BP over 24 hours recommended for lowering BP in hypertensive patients with ischemic stroke, nitroglycerin caused a >15% reduction of BP over the first 24 hours on 60% of the occasions used. Furthermore, despite concerns about sublingual nifedipine, this was the second most commonly prescribed agent. Surprisingly, the mean time to first BP measurement following initiation of antihypertensive therapy was 117 +/- 43 minutes in ischemic stroke and 88 +/- 89 minutes in hemorrhagic strokes.
Conclusions:
The current guidelines for management of acute poststroke hypertension appear to have little influence on prescribing patterns, leading to considerable variations in practice. Such variations, likely due to uncertainty caused by lack of evidence from randomised controlled trials, are intolerable as patients maybe submitted to nonstandardised, potentially harmful care such as inappropriate choice of antihypertensives and inadequate BP monitoring as observed in this study.