Emergency department adherence to American Heart Association guidelines for blood pressure management in acute ischemic stroke.
OBJECTIVE
Severely elevated blood pressure (BP) and aggressive BP reduction are both associated with poor outcome in acute ischemic stroke (AIS). In nontissue-type plasminogen activator patients, the American Heart Association recommends antihypertensive therapy only if BP is ≥ 220/120 mm Hg with a goal of 15% to 25% reduction in the first 24 hours. We hypothesized that patients with AIS often receive antihypertensives in the emergency department below the recommended threshold and that BP reduction is often >20%.


METHODS
In 2005, AIS cases were ascertained at all 16 hospitals in Greater Cincinnati. BP was recorded at emergency department presentation and before and after antihypertensive treatment. Hypertension was defined as BP ≥ 220/120 mm Hg. Chi-square and Mann-Whitney U tests were used for comparisons.


RESULTS
A total of 1739 patients with AIS met inclusion criteria. Median age was 72 years with 43% male and 25% black. Of 218 treated with antihypertensives, 65 (30.0%) met treatment criteria immediately before treatment. Treated patients were younger (66 versus 73 years, P<0.001) with greater stroke severity than untreated patients (National Institutes of Health Stroke Scale score 4 versus 3, P=0.028). Median change in systolic BP was -25 mm Hg (range, -96 to 25 mm Hg). Median percentage change in systolic BP was -12.3% (range, -49.2% to 16.1%). Systolic BP decreased > 20% in 52 treated patients (23.7%).


CONCLUSIONS
Only one third of patients with AIS treated with antihypertensives met American Heart Association-recommended treatment criteria, and the rate of change of BP was frequently greater than recommended. Further studies are warranted to determine the impact of practice patterns on AIS outcomes.
Departments of Emergency Medicine, University of Cincinnati, Cincinnati, OH 45267-0769, USA. erin.grise@uc.edu
Erin McDonough
EM
Grise
Opeolu
O
Adeoye
Christopher
C
Lindsell
Kathleen
K
Alwell
Charles
C
Moomaw
Brett
B
Kissela
Dan
D
Woo
Matthew
M
Flaherty
Simona
S
Ferioli
Pooja
P
Khatri
Joseph
J
Broderick
Dawn
D
Kleindorfer
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000572:American Heart Association; D000959:Antihypertensive Agents / Q000627:therapeutic use; D001794:Blood Pressure / Q000502:physiology*; D002545:Brain Ischemia / Q000150:complications / Q000628:therapy*; D004632:Emergency Medical Services / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000188:drug therapy; D007629:Kentucky; D008297:Male; D008875:Middle Aged; D009820:Ohio; D012189:Retrospective Studies; D020521:Stroke / Q000209:etiology / Q000628:therapy*; D014481:United States; D055815:Young Adult
D000959:Antihypertensive Agents