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 basal ganglia stroke resulting in hemiplegia, and acute kidney injury (AKI), who is currently on aspirin and Plavix (clopidogrel)?

From the Guidelines

This patient requires immediate management of his hypertensive emergency with careful blood pressure control using IV labetalol or nicardipine, aiming for a gradual reduction of 15-25% within the first 24 hours to avoid hypoperfusion of the penumbra area, as recommended by the guidelines for the early management of patients with ischemic stroke 1. The patient's presentation with a right basal ganglia stroke resulting in hemiplegia, complicated by acute kidney injury (AKI) during rehabilitation, necessitates a comprehensive approach to management.

• The blood pressure management should be guided by the principles outlined in the guidelines for the early management of patients with ischemic stroke, which suggest that elevated blood pressure should be lowered cautiously, with parenteral agents such as labetalol or nicardipine being preferred 1.
• For secondary stroke prevention, dual antiplatelet therapy with aspirin 81mg daily and clopidogrel 75mg daily for 21 days, followed by transition to a single antiplatelet agent long-term, is recommended.
• The AKI requires nephrology consultation, medication adjustment, and careful fluid management, with consideration of holding diuretics and nonselective beta-blockers, discontinuing NSAIDs, and replacing fluid losses, as suggested by the AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis 1.
• Blood pressure medications should be adjusted considering the kidney injury, potentially using amlodipine 5-10mg daily, which has less renal impact.
• The patient's orientation only to person indicates cognitive impairment requiring neuropsychological evaluation.
• Physical and occupational therapy should be continued for hemiplegia rehabilitation.
• Given his multiple risk factors (hypertension, hyperlipidemia, previous stroke), aggressive risk factor modification is essential, including statin therapy (atorvastatin 40-80mg daily), blood pressure control targeting <130/80 mmHg, and lifestyle modifications including sodium restriction, regular physical activity as tolerated, and smoking cessation if applicable.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Presentation

• The patient is a 70-year-old male with a history of hypertension, hyperlipidemia, and a prior stroke in 2015.
• He presents with a hypertensive emergency and a right-sided basal ganglia stroke, resulting in hemiplegia.
• The patient is also on aspirin and Plavix.

Management of Hypertensive Emergency

• According to 2, the management of patients with hypertensive emergencies must be ensured in an intensive care unit, and must include the parenteral administration of antihypertensive drugs and accurate blood pressure monitoring.
• The recommended goals of treatment are a reduction of mean arterial pressure by no more than 20% during the first few hours, to avoid inducing severe ischemic injury in major organs.

Comparison of Antihypertensive Agents

• Studies have compared the efficacy and safety of nicardipine and clevidipine in the management of hypertension in acute cerebrovascular diseases, including 3, 4, and 5.
• These studies suggest that both nicardipine and clevidipine are effective and safe in reducing blood pressure in patients with acute stroke, although there may be differences in terms of cost and volume restriction.
• For example, 3 found that nicardipine achieved an SBP goal of <160 mm Hg at 2-6 h significantly more often than the clevidipine group.
• In contrast, 4 found that clevidipine administration resulted in significantly less volume administered per patient versus nicardipine.

Considerations for Patient Management

• Given the patient's history of stroke and current presentation with a hypertensive emergency, careful management of blood pressure is crucial to prevent further ischemic injury.
• The choice of antihypertensive agent will depend on various factors, including the patient's medical history, current blood pressure, and the presence of any contraindications or allergies.
• As noted in 6, clevidipine has a rapid onset and short duration of action, making it a potentially useful option for managing acute hypertension in this patient population.