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*For reference by medical professionals
only, nicardipine is preferred for perioperative blood pressure lowering whether it is ischemic or hemorrhagic cerebrovascular disease
.
Cerebrovascular disease is a common acute and severe disease in clinical practice, with high morbidity, high disability rate and high mortality, which seriously threatens people's life and health
.
Hypertension plays a pivotal role in the onset and prognosis of cerebrovascular disease, and is also a risk factor
directly related to death in patients with cerebrovascular disease and significantly affects the prognosis.
Therefore, controlling hypertension is a top priority in the perioperative management of cerebrovascular disease
.
Based on this, this issue of the "Urgent Threesome: Big Coffee Online" expert interview forum specially invited Professor Wang Chunlei of the First Affiliated Hospital of Harbin Medical University as the host of the conference, Professor Xu Shancai of the First Affiliated Hospital of Harbin Medical University and Professor Wen Zhifeng of the First Affiliated Hospital of China Medical University gathered in the cloud to discuss the perioperative blood pressure management strategies
of patients with cerebrovascular diseases.
Cerebrovascular disease is currently the world's leading cause of death, and in recent years has occupied the first cause of death in China [1].
Hypertension is the most common risk factor for cerebrovascular disease, and approximately two-thirds of patients have a history of hypertension prior to onset [2].
According to different etiologies, cerebrovascular diseases are mainly divided into two categories: ischemic cerebrovascular disease and hemorrhagic cerebrovascular disease, of which ischemic cerebrovascular disease accounts for more than 60% of the total number of diseases [3].
"It is very important
to control blood pressure in the acute phase after the onset of cerebrovascular disease.
" Professor Xu Shancai said, "For different types of cerebrovascular diseases, treatment has both commonality and characteristics
.
"
Like ischemic cerebrovascular disease, due to the occlusion of the intracranial artery or carotid artery, the corresponding brain region is ischemic and hypoxic, and if the blood pressure drops sharply, it may threaten perfusion in key areas (hypoperfusion leads to dysfunction) [4].
Therefore, patients with ischemic cerebrovascular disease should be treated with intravenous thrombolysis early after the indication is evaluated, and blood pressure should be controlled within a certain range [5].
For hemorrhagic cerebrovascular disease, rapid intensive antihypertensive therapy should be implemented to reduce hematoma growth, thereby
benefiting the patient clinically.
In this regard, Professor Wen Zhifeng holds the same view: "The antihypertensive goals of hemorrhagic cerebrovascular disease and ischemic cerebrovascular disease are not the same, and clinically we should combine the patient's condition and rely on the monitoring methods of neurological severe disease for individualized management of target blood pressure
.
" ”
So, how should different types of cerebrovascular diseases be managed individually? In this interview forum, Professor Xu Shancai and Professor Wen Zhifeng introduced the antihypertensive goals
of hemorrhagic cerebrovascular disease and ischemic cerebrovascular disease respectively.
Professor Xu Shancai pointed out that in hemorrhagic cerebrovascular disease, hypertension is not only a common starting factor, but also a key factor affecting the prognosis in the course of the disease, and excessive blood pressure may lead to hematoma enlargement and deterioration of neurological function [6].
Therefore, for such patients, blood pressure lowering must be "early, rapid, and intensive"
.
According to the "American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage", if the systolic blood pressure of patients with intracranial hemorrhage is 150~220mmHg, in the absence of contraindications to acute blood pressure treatment, reducing systolic blood pressure to 140mmHg can effectively improve the prognosis [7].
。 If systolic blood pressure > 180mmHg and evidence of increased intracranial pressure, it is recommended to keep the cerebral perfusion pressure at 61~80mmHg [8].
Professor Wen Zhifeng introduced the key to blood pressure management in ischemic cerebrovascular disease - it is necessary to choose different strategies according to the stage of the disease, especially paying attention to the separation
of blood pressure management before and after vascular recanalization.
Patients with acute ischemic cerebrovascular disease should minimize blood pressure intervention and adopt tolerant hypertension strategies before vascular recanalization, so as to protect the ischemic semi-dark band
.
Lowering blood pressure quickly, even to levels lower in the high blood pressure range
, is harmful.
Lowering blood pressure should therefore be cautiously lowered, and initiation of antihypertensive therapy is recommended only when systolic blood pressure > 220 mmHg or diastolic blood pressure > 120 mmHg, and with a maximum reduction of 15 percent over 24 hours [9].
After vascular recanalization, intensive antihypertensive should be implemented to reduce the occurrence of hyperperfusion, thereby reducing the degree of impairment of
cerebral vascular autoregulation.
"Whether it is hemorrhagic or ischemic cerebrovascular disease, blood pressure management is the most taboo to go high and low, and antihypertensive treatment must be stable!" Xu Shancai broke the "secret"
of perioperative blood pressure management of cerebrovascular disease.
Professor Wang Zhifeng also agrees with
this view.
For cerebrovascular emergencies, intravenous calcium-channel blockers (CCBs) are the first choice
for antihypertensive therapy.
Professor Xu Shancai affirmed the therapeutic effect of nicadipine: "As a commonly used CCB drug in clinical practice, nicadipine can expand cerebral blood vessels, reduce vasospasm, reduce intracranial pressure, and maintain cerebral perfusion, which is very important
for patients with cerebrovascular disease.
"
In fact, nicadipine has less effect on blood pressure variability than nitroprusside, nitroglycerin, or other potent diuretic antihypertensive drugs, making it a safe and effective antihypertensive option for patients with hemorrhagic cerebrovascular disease and can be safely used in all hypertensive emergencies [10].
。 In the absence of obvious contraindications to acute cerebral hemorrhage, it is recommended to use nicardipine to maintain systolic blood pressure at 130~180mmHg, and if there is a large amount of cerebral hemorrhage and obvious mass effect, further dehydration therapy with mannitol is required [11].
Professor Wen Zhifeng repeatedly emphasized that antihypertensive therapy in ischemic cerebrovascular diseases must be cautious, and it is necessary to grasp the patient's condition at the first time and formulate an individualized blood pressure management plan
.
In patients with ischemic cerebrovascular disease, lowering blood pressure without affecting cerebral perfusion will help maximize the preservation of neurological function
.
Mechanically, nicardipine mainly dilates spasmodic blood vessels and arterioles, and does not dilate veins, so it can ensure normal cerebral blood flow and does not directly affect intracranial pressure
.
More prominently, nicardipine lowers blood pressure most smoothly
compared with other antihypertensive drugs, such as β-blockers or ACE inhibitors.
In addition, nicardipine can rapidly lower blood pressure while dilating peripheral blood vessels, coronary arteries and renal
arterioles.
Therefore, whether from the perspective of antihypertensive efficacy or protection of target organs, nicardipine can be the preferred drug
for perioperative antihypertensive therapy in patients with cerebrovascular disease.
Summary Cerebrovascular
disease is a clinical acute and critical disease, with a dangerous condition and high
mortality.
Hypertension is closely related to the onset and prognosis of cerebrovascular disease, and the importance of perioperative blood pressure management is self-evident
.
The medication strategy needs to be individualized according to the condition, and the patient's blood pressure and intracranial pressure and other important signs should
be closely monitored.
As a classic CCB antihypertensive drug, nicardipine can quickly control blood pressure and timely inhibit the progression of hematoma or auto-regulatory function in the treatment of cerebrovascular disease, which is the priority choice for perioperative antihypertensive therapy in patients with cerebrovascular disease
.
Proportion of different subtypes of stroke in China.
Stroke.
2003 Sep; 34(9):2091-6.
[2]Alloubani A， Saleh A， Abdelhafiz I.
Hypertension and diabetes mellitus as a predictive risk factors for stroke［J］.
Diabetes Metab Syndr，2018，12（4）：577-584.
[3] ZHANG Dongyue,HAN Wei.
Research progress on stroke prevalence and risk factors in China[J].
World Latest Medical Information Digest,2018,18(80):122-123.
) [4]Prabhakaran S， Soltanolkotabi M， Honarmand AR， et al.
Perfusion-based selection for endovascular reperfusion therapy in anterior circulation acute ischemic stroke［J］.
AJNR Am J Neuroradiol，2014，35（7）：1303-1308.
[5]Saposnik G， Menon BK， Kashani N， et al.
Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke［J］.
Stroke，2019， 50（9）：2441-2447.
[6]Roh D， Sun CH， Murthy S， et al.
Hematoma Expansion Differences in Lobar and Deep Primary Intracerebral Hemorrhage ［J］.
Neurocrit Care，2019，31（1）：40-45.
[7]Kim JY， Bae HJ.
Spontaneous Intracerebral Hemorrhage：Management［J］.
J Stroke，2017，19（1）：28-39.
[8]Hemphill JC， Greenberg SM， Anderson CS， et al.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage：A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association［J］.
Stroke，2015，46（7）：2032-2060.
[9]Furie KL， Jayaraman MV.
2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke［J］.
Stroke， 2018，49（3）：509-510.
[10]van den Born BH, Lip GYH, Brguljan-Hitij J, et al.
ESC Council on hypertension position document on the management of hypertensive emergencies.
Eur Heart J Cardiovasc Pharmacother.
2019 Jan 1; 5(1):37-46.
[11] SUN Yingxian, ZHAO Lianyou, TIAN Gang, NIU Xiaolin, YIN Xinhua, LI Yuming, CAI Jun, XIE Liangdi, TAO Jun, CUI Zhaoqiang, GUO Yifang, CHEN Xiaoping, ZHANG Guogang, LI Yue, ZHENG Zeqi, GUO Zihong, HAN Qinghua, FENG Yingqing, WANG Shenghuang, HUANG Jing.
Chinese expert consensus on the problem of hypertensive emergency[J].
Chinese Journal of Hypertension,2022,30(03):207-218.
)
only, nicardipine is preferred for perioperative blood pressure lowering whether it is ischemic or hemorrhagic cerebrovascular disease
.
Cerebrovascular disease is a common acute and severe disease in clinical practice, with high morbidity, high disability rate and high mortality, which seriously threatens people's life and health
.
Hypertension plays a pivotal role in the onset and prognosis of cerebrovascular disease, and is also a risk factor
directly related to death in patients with cerebrovascular disease and significantly affects the prognosis.
Therefore, controlling hypertension is a top priority in the perioperative management of cerebrovascular disease
.
Based on this, this issue of the "Urgent Threesome: Big Coffee Online" expert interview forum specially invited Professor Wang Chunlei of the First Affiliated Hospital of Harbin Medical University as the host of the conference, Professor Xu Shancai of the First Affiliated Hospital of Harbin Medical University and Professor Wen Zhifeng of the First Affiliated Hospital of China Medical University gathered in the cloud to discuss the perioperative blood pressure management strategies
of patients with cerebrovascular diseases.
Blood pressure management is a key part of the treatment of cerebrovascular diseases
Cerebrovascular disease is currently the world's leading cause of death, and in recent years has occupied the first cause of death in China [1].
Hypertension is the most common risk factor for cerebrovascular disease, and approximately two-thirds of patients have a history of hypertension prior to onset [2].
According to different etiologies, cerebrovascular diseases are mainly divided into two categories: ischemic cerebrovascular disease and hemorrhagic cerebrovascular disease, of which ischemic cerebrovascular disease accounts for more than 60% of the total number of diseases [3].
"It is very important
to control blood pressure in the acute phase after the onset of cerebrovascular disease.
" Professor Xu Shancai said, "For different types of cerebrovascular diseases, treatment has both commonality and characteristics
.
"
Like ischemic cerebrovascular disease, due to the occlusion of the intracranial artery or carotid artery, the corresponding brain region is ischemic and hypoxic, and if the blood pressure drops sharply, it may threaten perfusion in key areas (hypoperfusion leads to dysfunction) [4].
Therefore, patients with ischemic cerebrovascular disease should be treated with intravenous thrombolysis early after the indication is evaluated, and blood pressure should be controlled within a certain range [5].
For hemorrhagic cerebrovascular disease, rapid intensive antihypertensive therapy should be implemented to reduce hematoma growth, thereby
benefiting the patient clinically.
In this regard, Professor Wen Zhifeng holds the same view: "The antihypertensive goals of hemorrhagic cerebrovascular disease and ischemic cerebrovascular disease are not the same, and clinically we should combine the patient's condition and rely on the monitoring methods of neurological severe disease for individualized management of target blood pressure
.
" ”
Separate treatments to ensure perioperative blood pressure lowering goals are achieved
So, how should different types of cerebrovascular diseases be managed individually? In this interview forum, Professor Xu Shancai and Professor Wen Zhifeng introduced the antihypertensive goals
of hemorrhagic cerebrovascular disease and ischemic cerebrovascular disease respectively.
Professor Xu Shancai pointed out that in hemorrhagic cerebrovascular disease, hypertension is not only a common starting factor, but also a key factor affecting the prognosis in the course of the disease, and excessive blood pressure may lead to hematoma enlargement and deterioration of neurological function [6].
Therefore, for such patients, blood pressure lowering must be "early, rapid, and intensive"
.
According to the "American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Management of Spontaneous Intracerebral Hemorrhage", if the systolic blood pressure of patients with intracranial hemorrhage is 150~220mmHg, in the absence of contraindications to acute blood pressure treatment, reducing systolic blood pressure to 140mmHg can effectively improve the prognosis [7].
。 If systolic blood pressure > 180mmHg and evidence of increased intracranial pressure, it is recommended to keep the cerebral perfusion pressure at 61~80mmHg [8].
Professor Wen Zhifeng introduced the key to blood pressure management in ischemic cerebrovascular disease - it is necessary to choose different strategies according to the stage of the disease, especially paying attention to the separation
of blood pressure management before and after vascular recanalization.
Patients with acute ischemic cerebrovascular disease should minimize blood pressure intervention and adopt tolerant hypertension strategies before vascular recanalization, so as to protect the ischemic semi-dark band
.
Lowering blood pressure quickly, even to levels lower in the high blood pressure range
, is harmful.
Lowering blood pressure should therefore be cautiously lowered, and initiation of antihypertensive therapy is recommended only when systolic blood pressure > 220 mmHg or diastolic blood pressure > 120 mmHg, and with a maximum reduction of 15 percent over 24 hours [9].
After vascular recanalization, intensive antihypertensive should be implemented to reduce the occurrence of hyperperfusion, thereby reducing the degree of impairment of
cerebral vascular autoregulation.
"Sudden high and low is the most taboo!" Nicardipine is the drug of choice for blood pressure management
"Whether it is hemorrhagic or ischemic cerebrovascular disease, blood pressure management is the most taboo to go high and low, and antihypertensive treatment must be stable!" Xu Shancai broke the "secret"
of perioperative blood pressure management of cerebrovascular disease.
Professor Wang Zhifeng also agrees with
this view.
For cerebrovascular emergencies, intravenous calcium-channel blockers (CCBs) are the first choice
for antihypertensive therapy.
Professor Xu Shancai affirmed the therapeutic effect of nicadipine: "As a commonly used CCB drug in clinical practice, nicadipine can expand cerebral blood vessels, reduce vasospasm, reduce intracranial pressure, and maintain cerebral perfusion, which is very important
for patients with cerebrovascular disease.
"
In fact, nicadipine has less effect on blood pressure variability than nitroprusside, nitroglycerin, or other potent diuretic antihypertensive drugs, making it a safe and effective antihypertensive option for patients with hemorrhagic cerebrovascular disease and can be safely used in all hypertensive emergencies [10].
。 In the absence of obvious contraindications to acute cerebral hemorrhage, it is recommended to use nicardipine to maintain systolic blood pressure at 130~180mmHg, and if there is a large amount of cerebral hemorrhage and obvious mass effect, further dehydration therapy with mannitol is required [11].
Professor Wen Zhifeng repeatedly emphasized that antihypertensive therapy in ischemic cerebrovascular diseases must be cautious, and it is necessary to grasp the patient's condition at the first time and formulate an individualized blood pressure management plan
.
In patients with ischemic cerebrovascular disease, lowering blood pressure without affecting cerebral perfusion will help maximize the preservation of neurological function
.
Mechanically, nicardipine mainly dilates spasmodic blood vessels and arterioles, and does not dilate veins, so it can ensure normal cerebral blood flow and does not directly affect intracranial pressure
.
More prominently, nicardipine lowers blood pressure most smoothly
compared with other antihypertensive drugs, such as β-blockers or ACE inhibitors.
In addition, nicardipine can rapidly lower blood pressure while dilating peripheral blood vessels, coronary arteries and renal
arterioles.
Therefore, whether from the perspective of antihypertensive efficacy or protection of target organs, nicardipine can be the preferred drug
for perioperative antihypertensive therapy in patients with cerebrovascular disease.
Summary Cerebrovascular
disease is a clinical acute and critical disease, with a dangerous condition and high
mortality.
Hypertension is closely related to the onset and prognosis of cerebrovascular disease, and the importance of perioperative blood pressure management is self-evident
.
The medication strategy needs to be individualized according to the condition, and the patient's blood pressure and intracranial pressure and other important signs should
be closely monitored.
As a classic CCB antihypertensive drug, nicardipine can quickly control blood pressure and timely inhibit the progression of hematoma or auto-regulatory function in the treatment of cerebrovascular disease, which is the priority choice for perioperative antihypertensive therapy in patients with cerebrovascular disease
.
References:
[1]Zhang LF, Yang J, Hong Z, et al; Collaborative Group of China Multicenter Study of Cardiovascular Epidemiology.Proportion of different subtypes of stroke in China.
Stroke.
2003 Sep; 34(9):2091-6.
[2]Alloubani A， Saleh A， Abdelhafiz I.
Hypertension and diabetes mellitus as a predictive risk factors for stroke［J］.
Diabetes Metab Syndr，2018，12（4）：577-584.
[3] ZHANG Dongyue,HAN Wei.
Research progress on stroke prevalence and risk factors in China[J].
World Latest Medical Information Digest,2018,18(80):122-123.
) [4]Prabhakaran S， Soltanolkotabi M， Honarmand AR， et al.
Perfusion-based selection for endovascular reperfusion therapy in anterior circulation acute ischemic stroke［J］.
AJNR Am J Neuroradiol，2014，35（7）：1303-1308.
[5]Saposnik G， Menon BK， Kashani N， et al.
Factors Associated With the Decision-Making on Endovascular Thrombectomy for the Management of Acute Ischemic Stroke［J］.
Stroke，2019， 50（9）：2441-2447.
[6]Roh D， Sun CH， Murthy S， et al.
Hematoma Expansion Differences in Lobar and Deep Primary Intracerebral Hemorrhage ［J］.
Neurocrit Care，2019，31（1）：40-45.
[7]Kim JY， Bae HJ.
Spontaneous Intracerebral Hemorrhage：Management［J］.
J Stroke，2017，19（1）：28-39.
[8]Hemphill JC， Greenberg SM， Anderson CS， et al.
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage：A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association［J］.
Stroke，2015，46（7）：2032-2060.
[9]Furie KL， Jayaraman MV.
2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke［J］.
Stroke， 2018，49（3）：509-510.
[10]van den Born BH, Lip GYH, Brguljan-Hitij J, et al.
ESC Council on hypertension position document on the management of hypertensive emergencies.
Eur Heart J Cardiovasc Pharmacother.
2019 Jan 1; 5(1):37-46.
[11] SUN Yingxian, ZHAO Lianyou, TIAN Gang, NIU Xiaolin, YIN Xinhua, LI Yuming, CAI Jun, XIE Liangdi, TAO Jun, CUI Zhaoqiang, GUO Yifang, CHEN Xiaoping, ZHANG Guogang, LI Yue, ZHENG Zeqi, GUO Zihong, HAN Qinghua, FENG Yingqing, WANG Shenghuang, HUANG Jing.
Chinese expert consensus on the problem of hypertensive emergency[J].
Chinese Journal of Hypertension,2022,30(03):207-218.
)
This material is for healthcare professionals only and should not be distributed
to non-healthcare professionals.
