What alternative medication can be given to a patient not eligible for thrombolysis to manage hypertension?

Management of Hypertension in Patients Not Eligible for Thrombolysis

In patients with acute ischemic stroke who are not eligible for thrombolytic therapy, hypertension should not be routinely treated unless blood pressure exceeds 220/120 mmHg. 1, 2

Blood Pressure Management Algorithm

When NOT to Treat:

• For patients with BP <220/120 mmHg:
  • Avoid antihypertensive treatment in the acute phase
  • Lowering BP may exacerbate existing ischemia by reducing perfusion to the ischemic penumbra 1, 2

When Treatment is Required:

• For extreme BP elevation (SBP >220 mmHg or DBP >120 mmHg):
  • Reduce BP by approximately 15%, and not more than 25%, over the first 24 hours 1
  • Gradual reduction thereafter to targets for long-term secondary stroke prevention

First-Line Medication Options:

1. Labetalol:

   • Dosing: 10-20 mg IV over 1-2 minutes
   • May be repeated or doubled every 10 minutes to maximum of 300 mg
   • Advantage: Leaves cerebral blood flow relatively intact 2
   • Median time to BP control: approximately 10 minutes 3

2. Nicardipine:

   • Dosing: 5 mg/hr IV infusion
   • Titrate by increasing 2.5 mg/hr every 5 minutes to maximum of 15 mg/hr
   • FDA-approved for short-term treatment of hypertension when oral therapy is not feasible 4
   • Median time to BP control: approximately 22 minutes 3

Second-Line Options:

• Sodium nitroprusside: For refractory hypertension or DBP >140 mmHg
  • Initial dose: 0.5 μg/kg/min IV infusion
  • Use with caution due to potential increases in intracranial pressure 2

Monitoring Recommendations

• Monitor BP every 15 minutes during active treatment
• Avoid rapid or excessive lowering of BP as this might exacerbate existing ischemia 1
• Pharmacological agents should be chosen to avoid precipitous falls in blood pressure 1

Transition to Long-Term Management

• Initiate or restart oral antihypertensive medications before hospital discharge 2
• For long-term secondary prevention:
  • Target BP <130/80 mmHg 1, 2
  • Preferred agents: ACE inhibitors, ARBs, thiazide diuretics 1, 2
  • For non-Black patients: Start with low dose ACEI/ARB 1
  • For Black patients: Consider ARB + dihydropyridine CCB or thiazide-like diuretic 1

Special Considerations

• Lower BP targets may be appropriate for patients with comorbidities like acute myocardial infarction, heart failure, or aortic dissection 2
• The choice of agents for managing blood pressure should be based on current Hypertension Canada Blood Pressure treatment guidelines 1
• Consider an individualized approach to antihypertensive medication selection based on patient comorbidities 1

Common Pitfalls to Avoid

1. Treating hypertension too aggressively in acute stroke patients not receiving thrombolytics
2. Failing to recognize that cerebral autoregulation is impaired in stroke, making the brain vulnerable to hypoperfusion if BP is lowered too quickly
3. Delaying transition to oral antihypertensive therapy for long-term secondary prevention
4. Using inadequate initial dosing of antihypertensive treatment, which may prolong time to BP control 3

Remember that the management approach differs significantly between patients eligible for thrombolysis (who require BP <185/110 mmHg) and those who are not eligible, where permissive hypertension is generally the standard of care in the acute phase.