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Original Contribution
September 2008

Aggressive Blood Pressure–Lowering Treatment Before Intravenous Tissue Plasminogen Activator Therapy in Acute Ischemic Stroke

Author Affiliations

Author Affiliations: Departments of Neurology, University of Texas Health Science Center at Houston (Drs Martin-Schild, Hallevi, Barreto, Gonzales, Grotta, and Savitz), University of California, San Diego (Dr Albright), and University of Illinois Medical Center, Chicago (Dr Khaja). Dr Martin-Schild is now with the Department of Neurology, Tulane University Health Sciences Center, New Orleans, Louisiana.

Arch Neurol. 2008;65(9):1174-1178. doi:10.1001/archneur.65.9.1174

Background  Patients with acute ischemic stroke (AIS) commonly have elevated blood pressure (BP). Guidelines have recommended against treatment with intravenous tissue plasminogen activator (tPA) when aggressive measures such as continuous infusion with nicardipine hydrochloride are required to maintain BP lower than 185/110 mm Hg. We evaluated the effect of elevated BP and its management on clinical outcomes after tPA therapy in AIS.

Objectives  To evaluate safety and outcome in patients with AIS who require treatment to lower BP before tPA therapy and to compare safety and outcome in patients who received aggressive treatment with nicardipine with those who received labetalol hydrochloride before tPA.

Design  Retrospective review of medical records for all patients who received intravenous tPA within 3 hours of AIS onset.

Setting  Emergency department.

Patients  One hundred seventy-eight patients with AIS treated with tPA.

Main Outcome Measures  Occurrence of symptomatic intracerebral hemorrhage and neurologic deterioration.

Results  Fifty patients required BP lowering before tPA therapy. Twenty-four of these patients (48%) received nicardipine either after labetalol or as first-line therapy. Patients requiring antihypertensive agents had higher baseline blood glucose concentrations, incidence of hypertension, and National Institutes of Health Stroke Scale scores. The rate of adverse events and of modified Rankin score at discharge were not significantly different in patients without BP-lowering treatment compared with patients given either labetalol or nicardipine before intravenous tPA therapy.

Conclusions  Blood pressure lowering before intravenous tPA therapy, even using aggressive measures, may not be associated with a higher rate of hemorrhage or poor outcome. Data suggest that patients with AIS requiring aggressive treatment to lower BP should not be excluded from receiving tPA therapy. A prospective study is needed to support these conclusions.