What is the management approach for a 70-year-old patient with poorly controlled Hypertension (HTN), Diabetes Mellitus (DM), and a history of stroke in 2015 resulting in left-sided weakness, who presents with a hypertensive emergency and a recent right basal ganglia stroke, now exhibiting decreased alertness and inability to move the left side?

From the Guidelines

This patient requires immediate medical attention for a suspected new stroke or extension of the recent right basal ganglia stroke, and blood pressure management is critical to prevent further brain damage. The patient should be transported to the emergency department immediately for urgent neuroimaging (CT or MRI) to confirm the diagnosis. Time-sensitive interventions may include thrombolysis with IV tPA if within the appropriate time window (typically 4.5 hours from symptom onset) and if there are no contraindications 1. Endovascular thrombectomy might be considered if a large vessel occlusion is identified and the patient meets criteria.

• Blood pressure management is critical, with a target of <180/105 mmHg if thrombolysis is planned, using IV medications like labetalol (10-20 mg IV bolus) or nicardipine (5 mg/hr IV infusion, titrated as needed) 1.
• The patient will need admission to a stroke unit for close monitoring, comprehensive evaluation of stroke etiology, and initiation of secondary prevention measures.
• This should include antiplatelet therapy (aspirin 81-325 mg daily), high-intensity statin (atorvastatin 40-80 mg daily), and optimization of diabetes management (target HbA1c <7%) 1.
• Long-term antihypertensive therapy should be adjusted to achieve a target of <130/80 mmHg, typically with a combination of medications including an ACE inhibitor or ARB 1.
• Early rehabilitation should be initiated once the patient is medically stable. The deterioration in neurological status with new left-sided weakness and decreased alertness strongly suggests a new ischemic event, and rapid intervention is essential to minimize further brain damage and improve functional outcomes.

From the FDA Drug Label

Individualize dosing based on the severity of hypertension and the response of the patient during dosing. Monitor blood pressure and heart rate both during and after the infusion to avoid tachycardia or too rapid or excessive reduction in either systolic or diastolic blood pressure For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2.5 mg/hr to a maximum of 15 mg/hr until desired blood pressure reduction is achieved.

The patient is experiencing a hypertensive emergency, and nicardipine (IV) can be used to manage the condition.

• The initial dose should be 5 mg/hr.
• The dose can be increased by 2.5 mg/hr every 15 minutes for a gradual reduction in blood pressure or every 5 minutes for a rapid reduction.
• Monitor blood pressure and heart rate closely during and after the infusion to avoid complications.
• The maximum dose is 15 mg/hr. 2 2

From the Research

Patient Assessment

• The patient is 70 years old with a history of poorly controlled hypertension, diabetes, and a stroke in 2015 that resulted in left-sided weakness.
• The patient has recently experienced a hypertensive emergency and a right basal ganglia stroke about 10 days ago.
• Currently, the patient is only alert to person and cannot move their left side.

Management of Hypertensive Emergency

• According to 3, hypertensive emergency occurs when blood pressure is severely elevated (higher than 180 mm Hg systolic or higher than 120 mm Hg diastolic) and acute organ damage is present.
• Management of hypertensive emergency is directed at the specific situation, with the rate and extent of blood pressure lowering tailored to the type and extent of organ damage.

Blood Pressure Management in Acute Stroke

• Studies 4, 5, and 6 compared the efficacy of nicardipine and clevidipine in managing blood pressure in patients with acute stroke.
• These studies found no significant difference in blood pressure management between nicardipine and clevidipine.
• However, nicardipine appeared to have a lower risk of rebound hypertension and bradycardia compared to clevidipine 4.

Monitoring in Intensive Care

• According to 7, monitoring is essential in critical care to optimize patient's hemodynamic, ventilation, temperature, nutrition, and metabolism.
• Goal-directed therapy involves sequential optimization of heart function and judging the adequacy of perfusion/oxygenation on specific parameters.
• Regular monitoring of temperature, respiratory, nutritional, and metabolic care is also crucial in intensive care.