What is the management approach for a 70-year-old patient with poorly controlled Hypertension (high blood pressure), 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 with a computed tomography (CT) scan showing an evolving stroke in the basal ganglia?

From the Guidelines

For a 70-year-old patient with poorly controlled hypertension, diabetes, and history of stroke who is now experiencing neurological deterioration with left-sided weakness and decreased alertness after a recent right basal ganglia stroke, immediate hospitalization in a stroke unit or ICU is necessary. The patient should undergo urgent neuroimaging (MRI with diffusion-weighted imaging) to assess for stroke extension, hemorrhagic transformation, or cerebral edema. Blood pressure should be carefully managed, targeting systolic BP 140-160 mmHg initially, using IV medications like labetalol or nicardipine if needed, as per the guidelines from the American Heart Association/American Stroke Association 1. Maintain euglycemia with insulin therapy targeting blood glucose 140-180 mg/dL. Ensure adequate oxygenation, consider dysphagia screening before oral intake, and initiate early physical therapy. For secondary prevention, once stabilized, the patient should receive high-intensity statin therapy (atorvastatin 40-80 mg daily), antiplatelet therapy (clopidogrel 75 mg daily), and optimized antihypertensive and antidiabetic medications, as recommended by the European Heart Journal 1. This comprehensive approach addresses the acute deterioration while targeting the underlying vascular risk factors that contributed to the recurrent stroke.

Some key points to consider in the management of this patient include:

• The importance of careful blood pressure management, as both high and low blood pressure can be detrimental in the setting of acute stroke 1.
• The need for urgent neuroimaging to assess for stroke extension, hemorrhagic transformation, or cerebral edema 1.
• The importance of maintaining euglycemia and ensuring adequate oxygenation 1.
• The role of early physical therapy in improving outcomes after stroke 1.
• The need for secondary prevention measures, including high-intensity statin therapy, antiplatelet therapy, and optimized antihypertensive and antidiabetic medications, to reduce the risk of recurrent stroke 1.

Overall, the management of this patient requires a comprehensive and multidisciplinary approach, taking into account the latest evidence-based guidelines and recommendations from reputable sources 1.

From the FDA Drug Label

Administer Nicardipine Hydrochloride by slow continuous infusion by a central line or through a large peripheral vein. Titration 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 every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved.

For a patient with a hypertensive emergency, initiate nicardipine hydrochloride injection at a rate of 5 mg/hr and titrate every 15 minutes by increasing the infusion rate by 2.5 mg/hr until the desired blood pressure reduction is achieved, up to a maximum of 15 mg/hr 2.

• Monitor closely for hypotension or tachycardia and adjust the infusion rate as needed.
• Consider the patient's impaired cardiac, hepatic, or renal function when titrating nicardipine hydrochloride injection 2.
• The patient's evolving stroke and history of stroke should be taken into consideration when managing their blood pressure 2.

From the Research

Management of Hypertensive Emergency in a Patient with Stroke

• The patient is a 70-year-old with a history of poorly controlled hypertension, diabetes, and a previous stroke in 2015, presenting with a hypertensive emergency and a new stroke in the right basal ganglia.
• The primary goal is to manage the hypertensive emergency and prevent further stroke progression.

Blood Pressure Management

• According to the study by 3, nicardipine and clevidipine are both effective in managing blood pressure in hypertensive crisis, with nicardipine showing more sustained blood pressure control and a lower risk of rebound hypertension.
• The study by 4 also found that nicardipine and clevidipine have similar efficacy in reducing systolic blood pressure in patients with hemorrhagic stroke, but nicardipine had a lower risk of rebound hypertension and was more cost-effective.
• Another study by 5 compared nicardipine and clevidipine in acute stroke patients and found no significant difference in time to goal blood pressure, but nicardipine had a lower cost and volume restriction.

Treatment Options

• Nicardipine is a dihydropyridine-type Ca(2+) channel blocker with strong antihypertensive activity and a peculiar cerebrovascular profile, making it a suitable option for managing blood pressure in patients with stroke 6.
• Clevidipine is also a dihydropyridine calcium channel blocker that provides unique benefits for blood pressure control, but its use may be limited by its higher cost and volume restriction 3, 4.

Clinical Considerations

• The patient's history of stroke and current presentation with a new stroke in the right basal ganglia require careful consideration of the potential risks and benefits of each treatment option.
• The study by 7 found no difference in the mean time to goal systolic blood pressure between clevidipine and nicardipine in patients with acute ischemic stroke or spontaneous intracerebral hemorrhage.