Do we administer antihypertensives to patients with hypertension and elevated intracranial pressure (ICP)?

From the Guidelines

Antihypertensives should be administered to patients with high blood pressure and elevated intracranial pressure (ICP) with careful consideration, aiming to maintain cerebral perfusion pressure while reducing hypertension-related complications, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Considerations

• The goal is to maintain cerebral perfusion pressure while reducing the risk of hypertension-related complications.
• First-line agents often include labetalol, nicardipine, or clevidipine, which allow for tight blood pressure control with minimal effects on ICP.
• It's crucial to avoid rapid or excessive blood pressure reduction, as this could compromise cerebral perfusion and worsen neurological outcomes.

Treatment Approach

• In patients with acute intracerebral haemorrhage, immediate BP lowering is not recommended for patients with systolic BP <220 mmHg, but careful acute BP lowering with i.v. therapy to <180 mmHg should be considered for those with systolic BP ≥220 mmHg 1.
• In hypertensive patients with an acute cerebrovascular event, anti-hypertensive treatment is recommended immediately for TIA and after several days in ischemic stroke.
• Severe hypertension can be managed with drug treatment using i.v. labetalol, oral methyldopa, or nifedipine, with intravenous hydralazine as a second-line option.

Monitoring and Adjustments

• Continuous monitoring of both blood pressure and neurological status is essential during treatment to ensure adequate cerebral perfusion is maintained while managing hypertension.
• The target blood pressure should generally be no more than 20-25% below baseline in the acute setting, or systolic blood pressure around 140-160 mmHg, depending on the specific clinical scenario.

From the FDA Drug Label

In patients whose intracranial pressure is already elevated, sodium nitroprusside should be used only with extreme caution. In cases where there has been increased intracranial pressure, lowering the blood pressure may increase cerebral ischemia

Caution is advised when giving antihypertensives to patients with high blood pressure and high intracranial pressure (ICP).

• Sodium nitroprusside should be used with extreme caution in patients with elevated ICP 2.
• Hydralazine may increase cerebral ischemia if used to lower blood pressure in patients with increased ICP 3. It is recommended to exercise caution and carefully consider the potential risks and benefits before administering antihypertensives in this patient population.

From the Research

Blood Pressure Management in Patients with High ICP

• The management of blood pressure in patients with high intracranial pressure (ICP) is a critical aspect of their care, as elevated blood pressure can exacerbate ICP and worsen outcomes 4.
• Studies have investigated the use of antihypertensives, such as nicardipine and labetalol, in patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), and found them to be effective and safe for blood pressure control 5, 6.
• The optimal blood pressure target in patients with ICH is a subject of ongoing debate, but recent trials suggest that a systolic target of 140mmHg may be beneficial 7.
• Head elevation is also recommended as a tier zero measure to decrease high ICP in neurocritical patients, and has been shown to reduce ICP without significantly affecting cerebral perfusion pressure (CPP) or cerebral oxygenation 8.

Antihypertensive Use in Patients with High ICP

• Nicardipine and labetalol are two commonly used antihypertensives in patients with ICH and SAH, and have been shown to be effective and safe for blood pressure control 5, 6.
• The choice of antihypertensive agent may depend on individual patient factors, such as the presence of tachycardia or bradycardia, and the need for rapid blood pressure control 5.
• Continuous-infusion labetalol and nicardipine have been compared in several studies, and found to be comparable in terms of safety and efficacy 5, 6.

Considerations for Blood Pressure Management

• The timing and duration of blood pressure intervention are critical considerations in patients with ICH, and may depend on individual patient factors, such as the presence of hematoma expansion or poor functional outcomes 7.
• The intensity of blood pressure reduction is also an important consideration, and recent trials suggest that a systolic target of 140mmHg may be beneficial 7.
• The use of antihypertensives in patients with high ICP requires careful monitoring and adjustment to avoid excessive blood pressure reduction, which can worsen cerebral perfusion and outcomes 4, 5, 6.