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Only for medical professionals to read and reference From the mechanism to the treatment principle to the recommended medication, the wonderful content should not be missed
.
Intracerebral hemorrhage (ICH), a subtype of hemorrhagic stroke, accounts for 20%-30% of all stroke cases, and about 2 million people worldwide suffer from ICH every year
.
In clinical treatment, such patients are often complicated and difficult to handle, with many complications and high mortality
.
For a long time, how to improve the prognosis of patients with ICH has also been a key issue in the academic community, and strengthening and stable blood pressure reduction is an important principle of blood pressure management in the acute phase of ICH
.
Why practice strengthening and steady blood pressure reduction? What benefits can intensified steady blood pressure lowering bring to patients with ICH? On March 24, 2022, Prof.
Zhang Xiuzhong from the Western Theater General Hospital, as the host, joined Prof.
Huang Yi from Chongqing Ninth People's Hospital and Prof.
Liu Jinping from Sichuan Provincial People's Hospital as a guest in the live broadcast room of "Urgent and Heavy Threesome - Big Coffee Online".
Come and listen to the explanations of the three big coffees! Before lowering blood pressure, the mechanism must be clarified.
Professor Huang Yi pointed out that it is very common for ICH patients to have significantly higher blood pressure than the baseline blood pressure within 24 hours after the onset of ICH
.
Significant increases in blood pressure are particularly common when functional areas involved in blood pressure regulation, such as the insula, cingulate cortex, amygdala, prefrontal regions, or brainstem, are damaged or compressed
.
Damage to these areas triggers the release of hormones including aldosterone, angiotensin, and catecholamines and increases baroreceptor sensitivity
.
In addition, the cranial cavity is a closed space, and the hematoma caused by ICH can compress the brain parenchyma resulting in increased intracranial pressure and blood pressure
.
In conclusion, elevated blood pressure in patients with acute ICH is a composite outcome caused by multiple factors and mechanisms
.
After introducing the mechanism of blood pressure increase in the acute phase of ICH, Professor Liu Jinping proposed that blood pressure changes in the acute phase of ICH are closely related to the prognosis of patients, and transient blood pressure increase will also have adverse effects on cerebral blood perfusion
.
A transient increase in blood pressure can also easily lead to the expansion of the hematoma, which can lead to the displacement of brain tissue (brain herniation), which can lead to deterioration of neurological function
.
Hematoma expansion is an independent risk factor for poor prognosis in patients with ICH, even leading to death
.
Therefore, controlling blood pressure in patients with acute ICH is the key to improving prognosis
.
Professor Liu Jinping also emphasized that there are degrees in everything, and the same is true for lowering blood pressure
.
Excessive decompression can directly reduce cerebral perfusion and even cause iatrogenic ischemic stroke.
Therefore, for patients with ICH, only stable blood pressure control can fundamentally delay the expansion of hematoma
.
One step is not advisable, but strengthening stability is feasible.
Professor Zhang Xiuzhong further raised the question of blood pressure reduction: what principles should be followed for blood pressure reduction in patients with ICH? Professor Liu Jinping spoke first.
He believed that the development of an appropriate blood pressure management plan for ICH patients is the focus and difficulty of current clinical treatment.
The key is to balance the relationship between intracranial pressure, cerebral perfusion pressure and blood pressure fluctuations
.
Professor Liu Jinping pointed out that the management of blood pressure in the acute phase of ICH should adopt the method of strengthening and steady blood pressure reduction
.
Considering the slow onset of oral drugs and the inability of some patients to take oral drugs, intravenous preparations should be preferred, and blood pressure should be closely monitored during treatment to protect target organs
.
In general, it is necessary to adhere to the principle of individualization to achieve enhanced and stable blood pressure reduction
.
Professor Huang Yi reviewed his clinical experience for more than ten years and proposed that the concept he followed before has always been to maintain slightly high blood pressure in patients with acute ICH
.
This practice is designed to prevent ischemic events from falling too low, but it lacks evidence-based medical evidence
.
Nowadays, the effect of intensive blood pressure reduction in clinical practice and its improvement on prognosis have been gradually recognized.
The "China Hypertension Emergency Diagnosis and Treatment Standard" pointed out: ICH patients should actively use intravenous antihypertensive drugs to lower blood pressure to reduce bleeding and further aggravation risk
.
Several studies have shown that it is safe to reduce systolic blood pressure to less than 140mmHg within 6 hours of onset
.
The 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend that when the patient's systolic blood pressure is between 150-220 mmHg and there are no obvious contraindications, it is safe and effective to rapidly reduce systolic blood pressure to 140 mmHg
.
Professor Zhang Xiuzhong concluded that young patients have better vascular elasticity and can withstand a larger range of blood pressure; however, patients with island hemorrhage and storm eye on imaging should be reduced to a lower level; for patients with previous ischemic diseases , blood pressure control needs to be slightly conservative
.
Therefore, goal setting is only one aspect, and it is still necessary to individualize treatment according to patient characteristics
.
It needs to be generally stable and relatively fast
.
What are the benefits of smooth blood pressure reduction? What are the preferred drugs? The principle of decompression was clarified, and the guests further analyzed the benefits brought by stable decompression
.
Professor Huang Yi said that the antihypertensive treatment of ICH patients needs to consider issues such as organ tissue perfusion and intracranial pressure
.
Under the premise of safety, intensive and steady blood pressure reduction can effectively maintain cerebral perfusion pressure, reduce intracranial pressure, and improve prognosis
.
The INTERACT2 study showed that for patients with acute ICH, early intensive and steady blood pressure reduction to 130-139 mmHg is safe and beneficial, and can significantly improve the functional outcomes of patients
.
The post-hoc analysis also showed that the control of blood pressure in the acute phase of ICH at 130-139 mmHg was helpful to prevent the hematoma from expanding within 2 hours
.
Prof.
Liu Jinping affirmed Prof.
Huang Yi's opinion, and on this basis gave medication recommendations: "Intensifying stable blood pressure lowering requires the selection of antihypertensive drugs, combined with the pathophysiological characteristics of acute ICH, nitroglycerin and nitroprusside should be avoided.
For drugs such as sodium that may increase intracranial pressure, choose drugs with rapid onset and failure, and a clear dose-response relationship, such as nicardi, etc.
The
dose
of these drugs can be adjusted in time according to the changes in the patient's blood pressure and condition.
Avoid excessive blood pressure
.
" Nicardipine shows the advantages of reducing blood pressure and protecting the brain.
Professor Zhang Xiuzhong pointed out that, as a second-generation dihydropyridine calcium channel blocker, nicardipine has unique advantages in treating ICH hypertension and can inhibit the The influx of calcium ions in vascular smooth muscle cells, dilate blood vessels and exert a hypotensive effect
.
In addition, because nicardipine mainly dilates spasmodic blood vessels and tiny arteries, and does not dilate veins, it can ensure normal cerebral blood flow and does not directly affect intracranial pressure.
Compared with antihypertensive drugs, the ability to reduce blood pressure variability is also stronger
.
For ICH patients, it can reduce blood pressure without affecting cerebral perfusion, which will help to maximize the preservation of patient neurological function and reduce the disability rate and fatality rate of ICH
.
Professor Huang Yi further mentioned that, in addition to its mechanism advantages, its pharmacokinetic properties are also worth mentioning
.
Nicardipine has a rapid onset of action, and the peak concentration can be reached within 1 minute of injection, and the peak effect can be achieved within 2 to 3 minutes, which truly meets the requirements of strengthening and stable blood pressure reduction
.
Overall, as a classic intravenous antihypertensive drug, nicardipine can significantly benefit patients with ICH
.
Professor Huang Yi continued: "We should not only pay attention to the patient's blood pressure at the moment, but also pay attention to the blood pressure fluctuation of the patient.
.
This is also the reason why I prefer intravenous nicardipine in my clinical work.
Its blood pressure is stable and sustained and efficient
.
As long as the medication is sufficient and the transition is gradual, the baseline blood pressure of most patients can be smoothly lowered
.
"Professor Zhang Xiuzhong re-emphasized that the type of medication is one aspect, and the route of administration is another aspect.
The dosage, pumping speed, and time interval of blood pressure monitoring are equally important
.
In addition to medication, it is also necessary to pay attention to the individualized situation of the patient, such as whether the patient's position is Meet the requirements; whether the fixation band is tight after tracheotomy; whether the patient has factors such as pain and irritation that cause blood pressure to rise
.
In conclusion, the three professors gave a high evaluation of this exchange
.
Professor Zhang Xiuzhong reaffirmed nicardipine The clinical role of reducing blood pressure in acute phase of ICH patients quickly, steadily and efficiently
.
They reminded young doctors: returning to the clinic, returning to the individual patient, and paying attention to the individualized treatment of patients and diseases is the direction of future medicine, and that is what everyone should work hard and strive for.
goal
.
References: [1] Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J , Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators.
Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.
N Engl J Med.
2013 Jun 20;368(25):2355- 65.
2.
Hemphill JC 3rd, et al .
Stroke.
2015 Jul;46(7):2032-60.
3.
van den Born BJ, et al.
Neth J Med.
2011 May;69(5):248-55.
4.
Peacock WF, et al.
Crit Care.
2011;15(3): R157.
5.
Unger T, Borghi C, Charchar F, et al.
2020 International Society of Hypertension Global Hypertension Practice Guidelines.
Hypertension.
2020; 75(6): 1334- 1357.
Copyright Notice: This information is intended to help healthcare professionals better understand the latest developments in related disease areas
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
For informational use by healthcare professionals only
.
Such information is not intended to replace professional medical advice in any way and should not be considered medical advice
.
If such information is used for purposes other than understanding information, this site and the author do not assume relevant responsibilities
.
.
Intracerebral hemorrhage (ICH), a subtype of hemorrhagic stroke, accounts for 20%-30% of all stroke cases, and about 2 million people worldwide suffer from ICH every year
.
In clinical treatment, such patients are often complicated and difficult to handle, with many complications and high mortality
.
For a long time, how to improve the prognosis of patients with ICH has also been a key issue in the academic community, and strengthening and stable blood pressure reduction is an important principle of blood pressure management in the acute phase of ICH
.
Why practice strengthening and steady blood pressure reduction? What benefits can intensified steady blood pressure lowering bring to patients with ICH? On March 24, 2022, Prof.
Zhang Xiuzhong from the Western Theater General Hospital, as the host, joined Prof.
Huang Yi from Chongqing Ninth People's Hospital and Prof.
Liu Jinping from Sichuan Provincial People's Hospital as a guest in the live broadcast room of "Urgent and Heavy Threesome - Big Coffee Online".
Come and listen to the explanations of the three big coffees! Before lowering blood pressure, the mechanism must be clarified.
Professor Huang Yi pointed out that it is very common for ICH patients to have significantly higher blood pressure than the baseline blood pressure within 24 hours after the onset of ICH
.
Significant increases in blood pressure are particularly common when functional areas involved in blood pressure regulation, such as the insula, cingulate cortex, amygdala, prefrontal regions, or brainstem, are damaged or compressed
.
Damage to these areas triggers the release of hormones including aldosterone, angiotensin, and catecholamines and increases baroreceptor sensitivity
.
In addition, the cranial cavity is a closed space, and the hematoma caused by ICH can compress the brain parenchyma resulting in increased intracranial pressure and blood pressure
.
In conclusion, elevated blood pressure in patients with acute ICH is a composite outcome caused by multiple factors and mechanisms
.
After introducing the mechanism of blood pressure increase in the acute phase of ICH, Professor Liu Jinping proposed that blood pressure changes in the acute phase of ICH are closely related to the prognosis of patients, and transient blood pressure increase will also have adverse effects on cerebral blood perfusion
.
A transient increase in blood pressure can also easily lead to the expansion of the hematoma, which can lead to the displacement of brain tissue (brain herniation), which can lead to deterioration of neurological function
.
Hematoma expansion is an independent risk factor for poor prognosis in patients with ICH, even leading to death
.
Therefore, controlling blood pressure in patients with acute ICH is the key to improving prognosis
.
Professor Liu Jinping also emphasized that there are degrees in everything, and the same is true for lowering blood pressure
.
Excessive decompression can directly reduce cerebral perfusion and even cause iatrogenic ischemic stroke.
Therefore, for patients with ICH, only stable blood pressure control can fundamentally delay the expansion of hematoma
.
One step is not advisable, but strengthening stability is feasible.
Professor Zhang Xiuzhong further raised the question of blood pressure reduction: what principles should be followed for blood pressure reduction in patients with ICH? Professor Liu Jinping spoke first.
He believed that the development of an appropriate blood pressure management plan for ICH patients is the focus and difficulty of current clinical treatment.
The key is to balance the relationship between intracranial pressure, cerebral perfusion pressure and blood pressure fluctuations
.
Professor Liu Jinping pointed out that the management of blood pressure in the acute phase of ICH should adopt the method of strengthening and steady blood pressure reduction
.
Considering the slow onset of oral drugs and the inability of some patients to take oral drugs, intravenous preparations should be preferred, and blood pressure should be closely monitored during treatment to protect target organs
.
In general, it is necessary to adhere to the principle of individualization to achieve enhanced and stable blood pressure reduction
.
Professor Huang Yi reviewed his clinical experience for more than ten years and proposed that the concept he followed before has always been to maintain slightly high blood pressure in patients with acute ICH
.
This practice is designed to prevent ischemic events from falling too low, but it lacks evidence-based medical evidence
.
Nowadays, the effect of intensive blood pressure reduction in clinical practice and its improvement on prognosis have been gradually recognized.
The "China Hypertension Emergency Diagnosis and Treatment Standard" pointed out: ICH patients should actively use intravenous antihypertensive drugs to lower blood pressure to reduce bleeding and further aggravation risk
.
Several studies have shown that it is safe to reduce systolic blood pressure to less than 140mmHg within 6 hours of onset
.
The 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend that when the patient's systolic blood pressure is between 150-220 mmHg and there are no obvious contraindications, it is safe and effective to rapidly reduce systolic blood pressure to 140 mmHg
.
Professor Zhang Xiuzhong concluded that young patients have better vascular elasticity and can withstand a larger range of blood pressure; however, patients with island hemorrhage and storm eye on imaging should be reduced to a lower level; for patients with previous ischemic diseases , blood pressure control needs to be slightly conservative
.
Therefore, goal setting is only one aspect, and it is still necessary to individualize treatment according to patient characteristics
.
It needs to be generally stable and relatively fast
.
What are the benefits of smooth blood pressure reduction? What are the preferred drugs? The principle of decompression was clarified, and the guests further analyzed the benefits brought by stable decompression
.
Professor Huang Yi said that the antihypertensive treatment of ICH patients needs to consider issues such as organ tissue perfusion and intracranial pressure
.
Under the premise of safety, intensive and steady blood pressure reduction can effectively maintain cerebral perfusion pressure, reduce intracranial pressure, and improve prognosis
.
The INTERACT2 study showed that for patients with acute ICH, early intensive and steady blood pressure reduction to 130-139 mmHg is safe and beneficial, and can significantly improve the functional outcomes of patients
.
The post-hoc analysis also showed that the control of blood pressure in the acute phase of ICH at 130-139 mmHg was helpful to prevent the hematoma from expanding within 2 hours
.
Prof.
Liu Jinping affirmed Prof.
Huang Yi's opinion, and on this basis gave medication recommendations: "Intensifying stable blood pressure lowering requires the selection of antihypertensive drugs, combined with the pathophysiological characteristics of acute ICH, nitroglycerin and nitroprusside should be avoided.
For drugs such as sodium that may increase intracranial pressure, choose drugs with rapid onset and failure, and a clear dose-response relationship, such as nicardi, etc.
The
dose
of these drugs can be adjusted in time according to the changes in the patient's blood pressure and condition.
Avoid excessive blood pressure
.
" Nicardipine shows the advantages of reducing blood pressure and protecting the brain.
Professor Zhang Xiuzhong pointed out that, as a second-generation dihydropyridine calcium channel blocker, nicardipine has unique advantages in treating ICH hypertension and can inhibit the The influx of calcium ions in vascular smooth muscle cells, dilate blood vessels and exert a hypotensive effect
.
In addition, because nicardipine mainly dilates spasmodic blood vessels and tiny arteries, and does not dilate veins, it can ensure normal cerebral blood flow and does not directly affect intracranial pressure.
Compared with antihypertensive drugs, the ability to reduce blood pressure variability is also stronger
.
For ICH patients, it can reduce blood pressure without affecting cerebral perfusion, which will help to maximize the preservation of patient neurological function and reduce the disability rate and fatality rate of ICH
.
Professor Huang Yi further mentioned that, in addition to its mechanism advantages, its pharmacokinetic properties are also worth mentioning
.
Nicardipine has a rapid onset of action, and the peak concentration can be reached within 1 minute of injection, and the peak effect can be achieved within 2 to 3 minutes, which truly meets the requirements of strengthening and stable blood pressure reduction
.
Overall, as a classic intravenous antihypertensive drug, nicardipine can significantly benefit patients with ICH
.
Professor Huang Yi continued: "We should not only pay attention to the patient's blood pressure at the moment, but also pay attention to the blood pressure fluctuation of the patient.
.
This is also the reason why I prefer intravenous nicardipine in my clinical work.
Its blood pressure is stable and sustained and efficient
.
As long as the medication is sufficient and the transition is gradual, the baseline blood pressure of most patients can be smoothly lowered
.
"Professor Zhang Xiuzhong re-emphasized that the type of medication is one aspect, and the route of administration is another aspect.
The dosage, pumping speed, and time interval of blood pressure monitoring are equally important
.
In addition to medication, it is also necessary to pay attention to the individualized situation of the patient, such as whether the patient's position is Meet the requirements; whether the fixation band is tight after tracheotomy; whether the patient has factors such as pain and irritation that cause blood pressure to rise
.
In conclusion, the three professors gave a high evaluation of this exchange
.
Professor Zhang Xiuzhong reaffirmed nicardipine The clinical role of reducing blood pressure in acute phase of ICH patients quickly, steadily and efficiently
.
They reminded young doctors: returning to the clinic, returning to the individual patient, and paying attention to the individualized treatment of patients and diseases is the direction of future medicine, and that is what everyone should work hard and strive for.
goal
.
References: [1] Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J , Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J; INTERACT2 Investigators.
Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage.
N Engl J Med.
2013 Jun 20;368(25):2355- 65.
2.
Hemphill JC 3rd, et al .
Stroke.
2015 Jul;46(7):2032-60.
3.
van den Born BJ, et al.
Neth J Med.
2011 May;69(5):248-55.
4.
Peacock WF, et al.
Crit Care.
2011;15(3): R157.
5.
Unger T, Borghi C, Charchar F, et al.
2020 International Society of Hypertension Global Hypertension Practice Guidelines.
Hypertension.
2020; 75(6): 1334- 1357.
Copyright Notice: This information is intended to help healthcare professionals better understand the latest developments in related disease areas
.
If copyright issues are involved, please contact us, and we will deal with it as soon as possible
.
For informational use by healthcare professionals only
.
Such information is not intended to replace professional medical advice in any way and should not be considered medical advice
.
If such information is used for purposes other than understanding information, this site and the author do not assume relevant responsibilities
.
