Blood Pressure Modification in Acute Stroke

February 2007

Blood Pressure Modification in Acute Stroke

Search Strategy: Recognizing that the management of acute ischemic stroke is a long-standing, prevalent problem you first search the leading source of therapeutic trials: the Cochrane Library. Using the search term “stroke and blood pressure” you obtain 30 citations, the second of which is a 33-page review on this exact topic. However, you realize the Cochrane review is dated (2001) and therefore perform a PUBMED search using Clinical Query narrow/specific therapy filters and obtain 1198 citations including 41 review articles. Fortunately, the 6th review article is a description of the Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS) Trial. You scan the bibliography of this article and find another systematic review from 2004 which provides you with the final two references through a bibliography search and Web of Science citation search.

A 57 year old man presents with the acute onset of left sided weakness and slurred speech just over 4 hours ago, which has remained essentially unchanged since onset. He has a past history of hypertension for which he takes hydrochlorothiazide and amlodipine. He denies diabetes, coronary artery disease, peripheral vascular disease, or renal disease. He smokes (one PPD) and denies cocaine or other illicit drug use. On neurological exam he is alert and oriented, but mildly dysarthric. He is noted to have a left facial droop and cannot completely lift his left arm against gravity. The left leg strength is normal. He has decreased sensation over his left arm and face. His NIHSS score is 7. A non-contrast CT of the head is read as normal. The rest of the exam shows that he is in normal sinus rhythm with a rate of 88/minute with a blood pressure of 210/120 (repeat after 20 minutes 214/122). The remainder of the exam is unremarkable. You ask yourself, Should this patient be treated acutely for hypertension? If so, to what target blood pressure?


PICO Question

Population: ED patients presenting with symptoms of acute ischemic stroke

Intervention: Anti-hypertensive medications to reduce blood pressure

Comparison: No attempts to alter blood pressure

Outcome: Post-stroke related mortality, functional outcome, adverse drug reactions including iatrogenic hypotension.


Years

First years: High Blood Pressure in Acute Stroke and Subsequent Outcome: A Systematic Review, Hypertension 2004; 43: 18-24.

Second years: Blood Pressure and Clinical Outcome in International Stroke Trial, Stroke 2002; 33: 1315-1320.

Third years: Interventions for Deliberately Altering BP in Acute Stroke, Cochrane Review 2001

Fourth years: Blood Pressure Management in Acute Stroke: A Long-Standing Debate, European Neurology 2006; 55: 123-135


Articles

Article 1: High Blood Pressure in Acute Stroke & Subsequent Outcome: A Systematic Review, Hypertension 2004; 43: 18-24.
ANSWER KEY

Article 2: BP and Clinical Outcomes in the International Stroke Trial, Stroke 2002; 33: 1315-1320
ANSWER KEY

Article 3: Interventions for deliberately altering BP in acute stroke, Cochrane Database of Systematic Reviews 2001, Issue 3, Art. No: CD000039. DOI: 10.1002/14651858.CD000039
ANSWER KEY

Article 4: Blood pressure management in acute stroke: A long-standing debate European Neurology 2006; 55: 123-135
ANSWER KEY


Strategy: PICO Question

Population: Adult emergency department patients with acute chest pain clinically concerning for PE

Intervention: Diagnostic tests (history, physical exam, V/Q, CT, MRI?) for ovarian torsion

Comparison: N/A

Outcome: Diagnostic accuracy (sensitivity, specificity, likelihood ration) for bedside physical exam, CT, V/Q, MRI.


Strategy: Years

First years: Clinical Policy: critical issues in the evaluation and management of adult patients presenting with suspected pulmonary embolism, Ann Emerg Med 2003; 41: 257-270. (http://pmid.us/12548278)

Second years: Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study, Ann Emerg Med 2010; 55: 307-315. (http://pmid.us/20045580)

Third years: Multidetector computed tomography for acute pulmonary embolism, NEJM 2006; 354: 2317-2327 (http://pmid.us/16738268)

Fourth years: Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial, JAMA 2007; 298: 2743-2753. (http://pmid.us/18165667)


Strategy: Articles

Article 1: Clinical Policy Critical Issues in the Evaluation and management of Adult Patients Presenting with Suspected Pulmonary Embolism, Ann Emerg Med 2003; 41257-270
ANSWER KEY

Article 2: Clinical Features from the History and Physical Examinations that Predict The Presence or Evidence of PE in Symptomatic ED Patients Results of a Prospective, Multicenter Study, Ann Emerg Med 2010; 55307

Article 3: Multidetector Computed Tomography for Acute Pulmonary Embolism (PIOPED II), NEJM 2006; 3542317-2327
ANSWER KEY

Article 4: Computed Tomographic Pulmonary Angiography vs Ventilation-Perfusion Lung Scanning in Patients with Suspected Pulmonary Embolism A Randomized Controlled Trial, JAMA 2007; 2982743-2753

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