What is the management approach for a 70-year-old male patient with a history of hypertension, hyperlipidemia, and prior stroke, presenting with a hypertensive emergency, right-sided stroke resulting in hemiplegia, and acute kidney injury (AKI), who is currently on aspirin and Plavix (clopidogrel)?

From the Guidelines

The immediate recommendation for this 70-year-old male patient with a hypertensive emergency and acute kidney injury (AKI) is to optimize blood pressure control using labetalol as the first-line treatment, while addressing the AKI by ensuring adequate hydration and monitoring renal function closely. The patient's history of hypertension, hyperlipidemia, and prior stroke, along with the current presentation of a right-sided stroke with hemiplegia, necessitates careful management of blood pressure to prevent further cerebral damage. According to the European Heart Journal study 1, labetalol is the preferred agent for managing hypertensive emergencies, including acute ischemic stroke, due to its ability to reduce blood pressure while maintaining cerebral blood flow.

The patient's AKI complicates the management, requiring careful consideration of nephrotoxic agents such as ACE inhibitors or ARBs, which should be temporarily reduced or held until kidney function improves 1. Dual antiplatelet therapy with aspirin and clopidogrel (Plavix) should be continued for secondary stroke prevention, but with close monitoring due to the AKI. The goal is to balance stroke prevention with kidney protection, as both are crucial for preventing recurrent stroke and further renal damage.

In terms of managing the AKI, ensuring adequate hydration is key, while avoiding volume overload, and monitoring renal function with daily creatinine levels to adjust medications accordingly. The study from Clinical Gastroenterology and Hepatology 1 provides guidance on managing AKI, although it is focused on patients with cirrhosis, the principles of careful fluid management and monitoring are applicable. Another study from the Journal of Hepatology 1 discusses the use of vasoconstrictors and albumin in the management of hepatorenal syndrome, which, while not directly applicable to this patient, highlights the importance of careful management of volume status and renal function in patients with AKI.

The patient's blood pressure should be managed aggressively, with a goal of reducing the mean arterial pressure (MAP) by 15% within the first hour, using labetalol as the first-line agent, as recommended by the European Heart Journal study 1. The patient's altered mental status, being only oriented to person, requires cognitive assessment and safety precautions to prevent further complications. Once the AKI resolves, a comprehensive antihypertensive regimen should be resumed, targeting a blood pressure goal of <130/80 mmHg, to prevent recurrent stroke and further cardiovascular events.

From the Research

Patient Presentation

• The patient is a 70-year-old male with a past medical history of hypertension, hyperlipidemia, and a prior stroke in 2015.
• He presents with a hypertensive emergency and a right-sided base of stroke, resulting in hemiplegia.
• The patient is oriented only to person and has been sent to rehab for final management of blood pressure and card pain.
• He is also on aspirin and plavix.

Management of Hypertensive Emergency

• According to 2, hypertensive emergencies must be treated immediately with intravenous antihypertensive medications to prevent progression of organ damage and death.
• The study by 3 compares the efficacy and safety of nicardipine and clevidipine for blood pressure control in hypertensive crisis, finding that nicardipine achieved an SBP goal of <160 mm Hg at 2-6 h significantly more often than the clevidipine group.
• 4 emphasizes the importance of prompt evaluation and treatment of hypertensive emergencies to prevent target-organ damage and catastrophic events.

Treatment Options

• Clevidipine is a calcium channel blocker that has been studied as a treatment option for hypertensive emergency, with favorable pharmacokinetics and clinical trials evaluating its use in emergency situations 5.
• Nicardipine and clevidipine are both dihydropyridine calcium channel blockers that provide unique benefits for blood pressure control, with nicardipine showing more sustained SBP control and a lower risk of rebound hypertension in some studies 3, 6.

Complications and Considerations

• The patient's rehab course is complicated by acute kidney injury (AKI), which is a potential safety outcome associated with the use of antihypertensive medications such as nicardipine and clevidipine 6.
• The choice of antihypertensive medication and treatment strategy should take into account the patient's individual needs and medical history, as well as the potential risks and benefits of each option 2, 3, 4, 5, 6.