CPG Hypertension

Guidelines for Stroke 2020

 Objective
To discuss the 2020 updates and Recommendations
for Hypertension Management among Stroke patients both in Hemorrhagic
and Ischemic Stroke.

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 Hello!

I am Jake Estaca
2nd Year Internal Medicine
Oct 2021

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About half a million Filipinos will be
affected by Stroke with an estimate of
$350 million to $1.2 billion needed to
meet the cost of Medical Care

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Hypertension is the most common
cause of death and disability
worldwide with its prevalence rising
in low to middle income countries.

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 Hypertension

▪ Hypertension is a major cause of premature death

worldwide.
▪ It is the most common important modifiable risk
factor for disability adjusted life-years lost
worldwide.
▪ Hypertension awareness in the Philippines is 67.8%.

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Hypertension

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 Cerebrovascular Diseases

▪ Abrupt onset of neurologic deficit that is attributable

to a focal Vascular Cause
▪ Second Leading cause of Death worldwide.
▪ Infarct: usually caused by thrombosis of the cerebral
vessels.
▪ Hemorrhage: caused by bleeding directly around the
brain.

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Stroke Case #1

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Patient S.M. 55 years old Male from Tagbilaran, who is
known Hypertensive for 10 years with poor compliance to
Medications was admitted for the first time due to Slurring
of speech and right sided body weakness for 2 hours.

Vital Signs:
200/100 mmhg
88 bpm
22 cpm
36.9 c
98% o2 (room air)
Wt: 70 kg

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Assessment:
Cerebrovascular disease infarct Right Middle Cerebral
Artery.

Plan:
- BP control
- IV thrombolysis

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Dilemma:
for adults with AIS who are eligible for IV
thrombolysis but not for mechanical thrombectomy,
what is the target blood pressure?

Recommendation:
For adults with AIS who are eligible for IV thrombolysis a
referral to a Neurologist is advised.

It is recommended that the BP should be maintained to

<185/110 mmhg prior and during treatment and <180/105
mmhg for the next 24 Hours after Treatment.

Clinical Question #16 2020 CPG for Hypertension

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Thrombolytic therapy also known as thrombolysis is a
treatment to dissolve dangerous blood clots in blood
vessels to improve blood flow and prevent damage to
tissue and organs.

Often used as an emergency treatment to dissolve blood

clots, that form in the arteries feeding the Heart or the
Brain.

It may involve injection of clot busting drugs through the

IV line or through a long catheter with a mechanical
device that removes or breaks the clot.

Thrombolytic Therapy
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Dilemma:
What is the recommended pharmacologic agent
recommended and dose to control Hypertension in
stroke

Recommendation:
Nicardipine 1-5mg/hr iv titrated by 2.5mg/hr every 5-15
minutes with maximum of 15mg/hr

Labetalol 10mg iv over 1-2 minutes followed by

continuous IV infusion of 2-8 mg/min may be used.

Clinical Question #16 2020 CPG for Hypertension

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Dilemma:
For adults with AIS who are not eligible for IV
thrombolysis or mechanical thrombectomy, what is the
target BP and threshold for pharmacological
management?

Recommendation:
Maintain MAP of 110-130 mmhg.

The threshold for urgent antihypertensive treatment is with

severe hypertension of SBP >220 od DBP >120, if with
severe hypertension it might be reasonable to reduce BP
by 15% during the first 24 hours after the onset of stroke.

Clinical Question #17 2020 CPG for Hypertension

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Management Proper:
Start Nicardipine 10mg+90cc PNSS at 10cc/hr (1mg/hr)
titrate by 5cc/hr every 15minutes, to maintain MAP of
110-130 mmhg.

Start Thrombolysis, give Human recombinant Tissue

Plasminogen Activator of 6mg IVTT bolus now then 57
mg iv Drip for 1 hour.

Monitor Blood pressure and sensorium changes.

Prognosis: Improved

Management
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Stroke Case #2

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Patient M.S. 68 years old male from Sagbayan, known
Hypertensive and Smoker and was admitted for the first
time due to complaints of Headaches, dizziness, vomiting
x1, slurring of speech and Right sided body weakness.

Vital Signs:
210/130 mmhg
71 bpm
28 cpm
37.1 c
94% o2 (room air)

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Assessment:
Cerebrovascular disease Bleed Left Middle cerebral artery.

Plan:
- Blood Pressure control

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Dilemma:
For adult patients with ICH, what is the threshold for
Bp lowering in the first few hours upon presentation at
the emergency room?

Recommendation:
For adult patients the threshold is SBP <180mmhg with
the use of Nicardipine as the first line of Treatment.

Clinical Question #18 2020 CPG for Hypertension

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Dilemma:
What would be the Target BP when lowering the blood
pressure in ICH?

Recommendation:
- The target SBP <180 mmhg
- In patients with SBP >180 mmhg, careful BP lowering to
140 to 160 mmhg should be considered.
- The magnitude of Bp reduction is dependent, avoiding
reductions >60 mmhg in 1 hour.
- It is also recommended not to lower BP acutely to <140
mmhg.

Clinical Question #18 2020 CPG for Hypertension

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Management Proper:
Start Nicardipine 10mg + 90cc PNSS at 10cc/hr (1mg/hr)
titrate by 5cc/hr every 15minutes to maintain SBP 160
mmhg

Prognosis: Guarded

Management
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 “
Summary

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 Hello!

I am Jake Estaca
2nd Year Internal Medicine
Oct 2021

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 “
The Good Physician treats the
Disease; The Great Physician treat
the Patient who has the Disease.

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 “
Thank you for Listening

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