What is the treatment for a 50-year-old man with facial palsy and hypertension (high blood pressure), with a blood pressure of 192/104 mmHg and a pulse of 66 beats per minute (bradycardia)?

From the Guidelines

For a 50-year-old man presenting with facial palsy and hypertension (192/104 mmHg) with a pulse of 66, the most appropriate initial treatment for the hypertension is labetalol, as it is effective for blood pressure control with minimal effect on heart rate and cerebral blood flow, according to the 2019 European Heart Journal guidelines 1.

Hypertension Management

The patient's blood pressure is significantly elevated, and immediate treatment is necessary to prevent further complications.

• The European Heart Journal guidelines recommend labetalol as the first-line treatment for hypertensive emergencies, including acute ischemic stroke and acute coronary events 1.
• The patient's pulse of 66 is relatively slow, which may indicate a lower risk of bradycardia with labetalol treatment.
• The 2020 International Society of Hypertension global hypertension practice guidelines recommend starting drug treatment immediately for grade 2 hypertension (≥160/100mmHg) 1.

Facial Palsy Management

For the facial palsy, which is likely Bell's palsy,

• prescribe prednisone 60 mg daily for 5 days followed by a 5-day taper (50 mg, 40 mg, 30 mg, 20 mg, 10 mg) to reduce inflammation of the facial nerve.
• add valacyclovir 1000 mg three times daily for 7 days to address potential viral causes.
• the patient should protect the affected eye with lubricating eye drops during the day and ointment at night, plus eye patching if unable to close the eye completely, to prevent corneal damage.

Monitoring and Follow-up

Blood pressure should be monitored regularly, with a target of <140/90 mmHg, and the patient should be followed up closely to adjust the treatment plan as needed.

• Early corticosteroid treatment (within 72 hours of symptom onset) significantly improves outcomes in Bell's palsy by reducing inflammation of the facial nerve.
• The patient's heart rate and blood pressure should be monitored closely during treatment to prevent bradycardia and hypotension.

From the FDA Drug Label

Labetalol produces dose-related falls in blood pressure without reflex tachycardia and without significant reduction in heart rate, presumably through a mixture of its alpha-blocking and beta-blocking effects. In a clinical pharmacologic study in severe hypertensives, an initial 0. 25 mg/kg injection of labetalol HCl, administered to patients in the supine position, decreased blood pressure by an average of 11/7 mmHg. Following discontinuation of intravenous treatment with labetalol HCl, the blood pressure rose gradually and progressively, approaching pretreatment baseline values within an average of 16 to 18 hours in the majority of patients Labetalol HCl administered as a continuous intravenous infusion, with a mean dose of 136 mg (27 to 300 mg) over a period of 2 to 3 hours (mean of 2 hours and 39 minutes) lowered the blood pressure by an average of 60/35 mmHg

For a 50-year-old man with facial palsy and hypertension (bp 192/104), labetalol (IV) can be considered as a treatment option to lower blood pressure.

• The initial dose of labetalol can be 0.25 mg/kg, which may decrease blood pressure by an average of 11/7 mmHg.
• The treatment should be administered with caution, considering the patient's condition and monitoring for potential side effects, such as postural hypotension.
• It is essential to monitor the patient's blood pressure and adjust the dose accordingly to achieve the desired therapeutic effect.
• The patient should not be allowed to move to an erect position unmonitored until their ability to do so is established 2.

From the Research

Treatment for Hypertension in Acute Stroke

The patient's blood pressure is 192/104, which is elevated. According to the studies, the goal is to lower the blood pressure to a safe range for thrombolytic therapy.

• The blood pressure goal for thrombolytic therapy is a systolic blood pressure less than or equal to 185 mmHg and a diastolic blood pressure less than or equal to 110 mmHg 3.
• Labetalol and nicardipine are two antihypertensive agents commonly used to manage elevated blood pressure in acute stroke patients.

Comparison of Labetalol and Nicardipine

Several studies have compared the efficacy and safety of labetalol and nicardipine in acute stroke patients:

• A study found that labetalol and nicardipine had similar effects on time to blood pressure control, with a median time of 10 minutes for labetalol, 22 minutes for nicardipine, and 15 minutes for hydralazine 3.
• Another study found that continuous-infusion labetalol and nicardipine had similar safety and efficacy outcomes, including time at goal blood pressure and blood pressure variability 4.
• A prospective study found that nicardipine achieved goal blood pressure more quickly and had better maintenance of blood pressure compared to labetalol 5.
• A study found that labetalol and nicardipine had similar safety and efficacy in controlling blood pressure for patients with acute stroke, with labetalol having a shorter time to goal blood pressure 6.
• A systematic review and meta-analysis found that nicardipine had a significantly superior effect on time at goal blood pressure compared to labetalol, but the incidence of adverse events was higher in the nicardipine group 7.

Treatment Approach

Based on the studies, both labetalol and nicardipine can be used to manage elevated blood pressure in acute stroke patients.

• The choice of antihypertensive agent may depend on the individual patient's characteristics and the clinical setting.
• It is essential to monitor the patient's blood pressure closely and adjust the treatment as needed to achieve the goal blood pressure range.
• The patient's facial palsy and pulse of 66 should also be considered when determining the treatment approach.