Original Article

Overuse of Antihypertensives in Patients with Acute Ischemic Stroke

Authors: Matthew Underwood, PharmD, Bob L. Lobo, PharmD, Christopher Finch, PharmD, James Wang, MD

Abstract

Background: The Stroke Council of the American Heart Association/American Stroke Association (AHA/ASA) recommends conservative management of hypertension (HTN) during acute ischemic stroke (AIS), although clinicians often manage blood pressure more aggressively. Our hypothesis was that aggressive management of HTN in patients with AIS is associated with hypotensive events and worsened neurologic outcomes.


Methods: The study was a retrospective, observational cohort of patients who were admitted to the hospital with AIS. Classification of neurologic outcomes was based on nurses’ neurologic assessments and were categorized as “worsened,” “stayed the same,” or “improved.” The accuracy of these assessments was verified by review of physician’s progress notes. Management of arterial HTN was recorded in all patients.


Results: Fifty medical records of patients with AIS who met inclusion criteria were reviewed. While only 22% of patients met the AHA/ASA criteria for hypertension treatment, 98% of the cohort were given antihypertensive therapy. Relative hypotension occurred in 64% of treated patients. Absolute hypotension associated with antihypertensive medications was uncommon but did occur in 2 of 15 patients who experienced neurologic worsening (13%), in 1 of 28 (3%) of patients who stayed the same, and in none of those who improved. Blood pressure was reduced excessively in all 11 of the patients who met AHA/ASA guidelines for treatment.


Conclusions: Adherence to AHA/ASA guidelines for HTN management during AIS was poor. Initiation or intensification of antihypertensive drugs was not associated with worsened neurologic outcomes. Furthermore, relative hypotension, absolute hypotension and excessive reductions in blood pressure were not associated with worsened neurologic outcomes.


Key Points


* The Stroke Council of the American Heart Association/American Stroke Association has published guidelines (Grade C, Level 5) addressing the proper management of hypertension in patients with acute ischemic stroke.


* This retrospective, observational cohort of patients with acute ischemic stroke documented poor compliance with the guidelines for treating blood pressure in acute ischemic stroke.


* There was no association between antihypertensive treatment that resulted in hypotension and adverse neurologic outcomes.

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