Unlock-Guidelines Management Hypertension

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Guidelines on the Management of Hypertension for the Prevention and Treatment of
Stroke and Hypertensive Emergencies

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NEUROLOGY
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Authors
Harold P. Adams, Jr, MD Mark J. Alberts, MD Stephen A. Mayer, MD
A ll ri gh i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM n M tio c 08 du 2 0 ro ep t R gh d. ri e py erv Co es r ts
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Table of Contents
Introduction
......................................................................................................................... .................................
4 5
Guidelines for the Management of Hypertension
Primary and Secondary Prevention of Ishemic Stroke....................... 7 Management of Hypertensive Emergencies Treatment of Acute Ischemic Stroke Treatment of Hemorrhagic Stroke
...........................................
22 27 33

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HAROLD P. ADAMS, JR, MD
Professor of Neurology Director, Divison of Cerebrovascular Diseases University of Iowa Carver College of Medicine Iowa City, Iowa
MARK J. ALBERTS, MD
Professor of Neurology Director, Stroke Program Northwestern University Feinberg School of Medicine Chicago, Illinois
DISCLAIMERThis pocket guide is designed to be a summary of information. Although it is detailed, it is not an exhaustive clinical review. McMahon Publishing, the sponsors, and the authors neither affirm nor deny the accuracy of the information contained herein. No liability will be assumed for the use of this pocket guide, and the absence of typographical errors is not guaranteed. Readers are strongly urged to consult any relevant primary literature. 2007, McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form.
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Management of Hypertension in the Setting of Elevated Intracranial Pressure ........................................................................... 36
List of Tables and Figures

Table 1. Table 2. End-Organ Effects of Chronic, Untreated Hypertension ................................................................................................ 4 Guidelines for the Classification and Management of Blood Pressure in Adults
............................
STEPHEN A. MAYER, MD
Associate Professor of Clinical Neurology and Neurosurgery Columbia University College of Physicians and Surgeons New York, New York
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Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9.
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Figure 1. Recommended treatment approach for hypertension ............................................................................................ 8-9 Overview of Oral Antihypertensive Agents ................ 10-15 2006 AHA/ASA Guidelines for the Management of Hypertension for the Primary Prevention of Ischemic Stroke.................................. 16
Figure 2. Algorithm for the management of hypertensive emergencies ..................................................... 20-21 The Ideal Parenteral Hypertensive ............................................ 22
Parenteral Agents for the Treatment of Hypertensive Emergencies ..................................................... 24-27 AHA/ASA Guidelines for the Management of Arterial Hypertension in Acute Ischemic Stroke .................................................................................................... 28-29
Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH ....................................... 30
I.V. Medications for Control of Elevated Blood Pressure in Patients With ICH ........................................................ 31
Table 10. 1994 AHA Guidelines on the Management of Subarachnoid Hemorrhage............................................................. 33 3
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Introduction
The treatment of hypertension is one of the most common reasons for visits to physicians in the United States and for the use of prescription drugs.1 The National Health Examination Surveys suggest that approximately 30% of patients older than 18 years of age have a diagnosis of hypertension,2,3 which translates into 58 to 65 million people with hypertension in the United States. These numbers are likely to increase as the population ages and the incidence of obesity increases.3 Untreated chronic hypertension has detrimental effects on diverse organ systems, including the brain (Table 1). In the hospital setting, the control of blood pressure has important implications for the acute management and primary and secondary prevention of various cerebrovascular diseases, including ischemic stroke, hemorrhagic stroke, and hypertensive encephalopathy. The purpose of this guide is to aid clinicians in understanding the evidence-based guidelines for the management of hypertension in patients with or at risk for
cerebrovascular disease. Specifically, the most recent guidelines from the American Heart Association (AHA), American Stroke Association (ASA), and the Joint National Committee (JNC) are reviewed.
Section I. Guidelines for the Management of Hypertension

Despite the prevalence of hypertension and its associated complications, control of the disease is far from adequate4,5; only 34% of persons with hypertension have their blood pressure under control, defined as a level below 140/90 mm Hg.6 The international REACH registry found that 40% of patients in North America with hypertension did not achieve blood pressure levels recommended by World Health Organization guidelines.7 This failure reflects the inherent problem of maintaining long-term therapy for a usually asymptomatic condition, particularly when the therapy may interfere with the patients quality of life and when its immediate benefits may not be obvious to the patient.
Table 1. End-Organ Effects of Chronic, Untreated Hypertension

Target Organ Damage Heart LVH Angina/prior MI Prior coronary revascularization Heart failure Brain Stroke or TIA Dementia CKD PAD Retinopathy
CKD, chronic kidney disease; LVH, left ventricular hypertrophy; MI, myocardial infarction; PAD, peripheral arterial disease; TIA, transient ischemic attack Adapted from reference 6
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Diagnosis Treatment
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The definition of hypertension continues to evolve. In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)6 issued a revised classification system of hypertension based on data from ALLHAT (Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial).8 Based on the average of 2 or more properly measured readings at each of 2 or more visits after an initial screen, patients may be classified as having normal blood pressure, prehypertension, stage 1 hypertension, or stage 2 hypertension (Table 2).
Antihypertensive medications should generally be initiated once the systolic blood pressure (SBP) is persistently above 140 mm Hg and/or if the diastolic blood pressure (DBP) is persistently above 90 mm Hg despite attempts at nonpharmacologic therapy, including improved diet and increased aerobic exercise (Figure 1).6 However, in patients with diabetes or proteinuric chronic renal failure, antihypertensive
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Table 2. Guidelines for the Classification and Management of Blood Pressure in Adults
Classification Normal Prehypertension Stage I hypertension Stage II hypertension SBP, mm Hg <120 120-139 140-159 160 DBP, mm Hg and <80 or 80-89
risk for orthostatic hypotension, such as those with diabetes or autonomic dysfunction and some older persons. Based on the JNC-7 guidelines, an ACE inhibitors, ARB, -blocker, or CCB can be added if thiazide monotherapy fails to attain adequate blood pressure control.6
Treatment of Special Populations

The JNC-7 guidelines recommend the use of specific antihypertensive agents for patients with compelling high-risk indications, including ischemic heart disease, heart failure, diabetes mellitus, chronic kidney disease, and cerebrovascular disease.6 The drug selections for these compelling indications are based on favorable outcome data from clinical trials. Rates of blood pressure control vary in minority populations and are lowest in Mexican Americans and Americans Indians.9,10 In African Americans, hypertension is more common and more severe, develops at an earlier age, and leads to more clinical sequelae than it does in age-matched nonHispanic whites.9 In clinical trials, lowering blood pressure prevents the sequelae of hypertension in all racial and ethnic groups.11-13 Nonetheless, monotherapy with -blockers, ACE inhibitors, or ARBs lowers blood pressure to a somewhat lesser degree in African Americans than in whites.12 In ALLHAT, which enrolled more than 15,000 African American participants, ACE inhibitors were less effective in lowering blood pressure than either thiazide-type diuretics or CCBs; the risk for stroke was 40% greater in African American patients treated with ACE inhibitors than in those treated with thiazide diuretics.8 Please see Section V for information on the treatment and management of hypertensive emergency.
DBP, diastolic blood pressure, SBP, systolic blood pressure Adapted from reference 6
therapy is indicated when the SBP is persistently above 130 mm Hg and/or the DBP is persistently above 80 mm Hg.6 A variety of pharmacologic agents are used for the treatment of hypertension, including diuretics, -blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs; Table 3). In the absence of high-risk hypertension or any other indication for specific antihypertensive therapy, the ALLHAT and JNC-7 guidelines recommend thiazide diuretics as the initial treatment of choice because of their high rate of efficacy, low rate of adverse effects, and low cost.6,8 The thiazide dose should be increased until the target blood pressure is achieved or until the maximal dose is reached. Many patients with hypertension will require 2 or more antihypertensive medications to achieve their blood pressure goals, especially if they have stage 2 hypertension. A second drug from a different class should be added when a single drug in adequate doses fails to achieve the goal blood pressure. When the blood pressure is more than 20/10 mm Hg above goal, initiating therapy with 2 drugs should be considered.6 Initiating drug therapy with more than 1 agent may increase the likelihood of achieving the blood pressure goal in a timely fashion, but particular caution is advised in patients at
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Section II. Primary and Secondary Prevention of Ischemic Stroke
The annual incidence of ischemic stroke in the United States is estimated to be more than 700,000. Ischemic stroke results in more than 160,000 deaths annually, making it the countrys third leading cause of death.14 Although stroke mortality declined 60% between 1968 and 1996, the rate of decline has plateaued during the most recent decade,15 and the incidence of stroke may be increasing.16 Stroke is a leading cause of
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Lifestyle modifications
Not at goal BP: <140/90 mm Hg (<130/80 mm Hg for patients with diabetes or CKD)
Initial drug choices
Drug choices for patients without compelling indications
Stage I hypertension Thiazide-type diuretics; consider also ACEI, ARB, BB, CCB
Figure 1. Recommended treatment approach for hypertension.
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Stage II hypertension 2-drug combination (ie, thiazide-type diuretics + ACEI or ARB or BB or CCB)
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Drug choices for patients with compelling indications
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Adapted from reference 6
Heart failure: Diuretic, BB, ACEI, ARB, AldoANT Post-MI: BB, ACEI, AldoANT High coronary disease risk: Diuretic, BB, ACEI, CCB Diabetes: Diuretic, BB, ACEI, ARB, CCB CKD: ACEI, ARB Recurrent stroke prevention: Diuretic, ACEI
Not at goal BP
Optimize doses or add additional drugs until goal BP achieved
ACEI, angiotensin-converting enzyme inhibitor; AldoANT, aldosterone antagonist; ARB, angiotensin receptor blocker; BB, -bocker; BP, blood pressure; CCB, calcium channel blocker; CKD, chronic kidney disease; MI, myocardial infarction
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Table 3. Overview of Oral Antihypertensive Agents

Class Thiazide diuretics Drug Chlorthalidone Chlorothiazide Hydrochlorothiazide Indapamide Metolazone Metolazone Usual Dose Range, mg/d 12.525 125500 12.5-50 1.252.5 Usual Daily Frequency 1 1-2 1 1 1 1 1 2 2 1 12 12 1 1 1 1 1 12 1 1 2 1 2 2 1
Polythiazide Loop diuretics Bumetanide Furosemide Torsemide Potassium-sparing diuretics Aldosterone receptor blockers BBs Amiloride Triamterene Eplerenone
Spironolactone Atenolol Betaxolol Bisoprolol Metoprolol Metoprolol extended-release Nadolol Propranolol Propranolol long-acting Timolol
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0.51.0 2.55 24 0.52 2080 2.510 510
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50100 50100 2550 25100 520 2.510 50100 50100 40120 40160 60180 2040
BBs with intrinsic sympathomimetic activity
Acebutolol Penbutolol Pindolol
200800 1040 1040
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Class Combined - and -blockers ACEIs Drug Carvedilol Labetalol Benazepril Captopril Enalapril Usual Dose Range, mg/d 12.550 200800 1040 25100
(continued) Usual Daily Frequency 2 2 1 2 12 1 1 1 1 1 1 1 1 12 1 12 1 1 12 1 1 1 2 12
Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Angiotensin II antagonists Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan CCBsNondihydropyridines
Diltiazem extended-release Diltiazem extended-release Verapamil Verapamil immediate-release Verapamil long-acting
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540 1040 1040 7.530 48 1080
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2.520 14 832 400800 150300 25100 2040 2080 80320 180420 120540 120360 80320 120480
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Class CCBs Dihydropyridines Drug Amlodipine Felodipine Isradipine Nicardipine sustained-release Nifedipine long-acting Nisoldipine -1 blockers Doxazosin Prazosin Terazosin Central -2 agonists and other centrally acting drugs Clonidine Clonidine patch Guanfacine Methyldopa Reserpine Direct vasodilators Hydralazine Minoxidil
ACEI, angiotensin-converting enzyme inhibitor; BB, -bocker; CCB, calcium channel blocker
(continued) Usual Dose Range, mg/d 2.510 2.520 2.510 60120 3060 1040 116 220 120 0.10.8 0.10.3 0.52 Usual Daily Frequency 1 1 2 2 1 1 1 23 12 2 1 weekly 1 2 1 2 12
* Dosing/scheduling based on individual drugs prescribing information.
functional impairments, with 20% of survivors requiring institutional care after 3 months and 15% to 30% permanently disabled.14 In 2004, the total cost of stroke in the United States was estimated at $53.6 billion, with a mean lifetime cost estimated at $140,048.14 Despite the advent of specific treatments for acute ischemic stroke, including I.V. tissue plasminogen activator, effective prevention remains the best method for reducing the burden of stroke.17,18
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2501,000 0.10.25 25100 2.580
Primary Prevention
The primary prevention of ischemic stroke is particularly important because more than 70% of all strokes are first events.14 The utility of prevention is underscored by various observational studies, such as one that reported a 40% decrease in the age-specific incidence of major stroke in Oxfordshire, UK, during the past 20 years in association with the use of preventive treatments and general reductions in risk factors.19
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Table 4. 2006 AHA/ASA Guidelines for the Management of Hypertension for the Primary Prevention of Ischemic Stroke
Summary The benefit of hypertension treatment for primary prevention of stroke is clear. Choice of a specific regimen must be individualized, but reduction in blood pressure is generally more important than the specific agent used to achieve this goal. Hypertension remains undertreated in the community, and programs to improve treatment compliance need to be developed and supported.
Recommendations
Regular screening for hypertension (at least every 2 years in most adults and more frequently in minority populations and the elderly) and appropriate management, including dietary changes, lifestyle modification, and pharmacological therapy as summarized in JNC-7 guidelines are recommended. Until ongoing trials define optimal general targets for blood pressure control, the AHA and ASA rely on the JNC-7 guidelines in recommending lowering blood pressure to <140/90 mm Hg (with lower targets in some subgroups).
Several risk factors for first ischemic stroke are well documented, with clear data showing a reduction in stroke risk with treatment, including management of hypertension, control of diabetes, and reduction in low-density lipoprotein cholesterol. In particular, hypertension is a major risk factor
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for cerebral infarction and intracerebral hemorrhage (ICH),3,20 and a direct correlation has been found between the degree and duration of hypertension and the risk for stroke.21 The evidence is compelling that the control of high blood pressure contributes to the prevention of stroke.6 Overall, antihypertensive therapy is associated with a 35% to 44% reduction in the incidence of stroke.22 However, it is not clear whether specific classes of antihypertensive agents offer special protection against stroke in addition to their blood pressurelowering effects in other settings. At least 1 study has compared the effects of an ARB with those of a -blocker in 9,193 persons with essential hypertension.23 Blood pressure reductions were similar for the 2 groups, but a 13% (relative risk [RR], 0.87; 95% confidence interval [CI], 0.77-0.98) reduction in myocardial infarction, stroke, or death was observed among the ARB-treated patients in comparison with those given a -blocker, which included a 25% (RR, 0.75; 95% CI, 0.63-0.89) reduction in fatal or nonfatal stroke. A meta-analysis of 18 long-term randomized trials found that both -blocker therapy (RR, 0.71; 95% CI, 0.59-0.86) and treatment with diuretics (RR, 0.49; 95% CI, 0.39-0.62) were effective in preventing stroke.24 Controlling isolated systolic hypertension (SBP >160 mm Hg and DBP <90 mm Hg) in the elderly is also important. The Syst-Eur (Systolic Hypertension in Europe) trial randomized 4,695 patients with isolated systolic hypertension to active treatment with a CCB or placebo and showed a 42% risk reduction in the actively treated group.25 SHEP (Systolic Hypertension in the Elderly Program) found that treatment with a thiazide diuretic with or without a -blocker achieved a 36% reduction in the incidence of stroke.26 Based on these data, the AHA and ASA issued joint guidelines in 2006 (Table 4) stating that the benefit of hypertension treatment for the primary prevention of stroke is clear.27 The choice of a specific regimen must be individualized, but reduction in blood pressure is generally more important than the specific agent used to achieve this goal. The guidelines noted that hypertension remains undertreated, and programs to improve treatment compliance need to be developed and supported according to the JNC-7 guidelines. Until ongoing trials define optimal general targets for blood pressure control, the AHA and ASA rely on the JNC-7 guidelines in recommending lowering blood pressure to below 140/90 mm Hg, with targets
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below 130/80 mm Hg in some subgroups (eg, patients with diabetes or proteinuric renal failure).
Secondary Prevention
Survivors of a transient ischemic attack (TIA) or stroke are at increased risk for another stroke, which is a major source of increased mortality and morbidity. Of the estimated 700,000 people who have a stroke in the United States each year, 200,000 have a recurrent stroke. More than 4.4 million stroke survivors are alive today,28 which underscores the importance of the secondary prevention of ischemic stroke. Among the risk factors that the 2006 guidelines from the AHA and ASA on the secondary prevention of ischemic stroke recommend be modified are hypertension, diabetes, hyperlipidemia, cigarette smoking, alcohol consumption, obesity, and sedentary lifestyle.29 Although a wealth of data from a variety of sources support the importance of treating hypertension for the primary prevention of cardiovascular disease in general and stroke in particular, only limited data directly address the role of blood pressure treatment in the secondary prevention of ischemic stroke.30 A systematic review focused on the relationship between blood pressure reduction and the secondary prevention of stroke and other vascular events. The analysis included 7 randomized controlled trials with a combined sample size of 15,527 participants who had had ischemic stroke, TIA, or ICH. The patients had been randomized from 3 weeks to 14 months after the index event and were followed for 2 to 5 years. Treatment with antihypertensive drugs was associated with significant reductions in all recurrent strokes and nonfatal recurrent strokes, with a similar, albeit nonsignificant, trend toward a reduction in fatal strokes. Data were stronger for patients treated with diuretics or diuretics and ACE inhibitors combined, but not for those treated with -blockers or ACE inhibitors alone.30 The overall reductions in stroke and all vascular events were related to the degree of blood pressure lowering achieved. Given these considerations, whether any one class of antihypertensive drug or any one drug within a given class offers a particular advantage for in patients after ischemic stroke remains uncertain. Much discussion has focused on the role of ACE inhibitors. HOPE (Heart Outcomes Prevention Evaluation) compared the ACE inhibitor ramipril with placebo in high-risk
persons and found a 24% reduction (95% CI, 5%-40%) in risk for stroke, myocardial infarction, or vascular death among the 1,013 patients with a history of stroke or TIA.31 Much of the stroke reduction came among patients with no prior history of stroke. In addition, all different types of stroke were reduced, including cerebral hemorrhage. PROGRESS (Perindopril [Aceon, Solvay] Protection Against Recurrent Stroke Study) was specifically designed to test the effects of a blood pressurelowering regimen, including an ACE inhibitor, in 6,105 patients who had had a stroke or TIA within the previous 5 years.32 Both hypertensive (>160 mm Hg systolic or >90 mm Hg diastolic) and nonhypertensive patients were randomized to monotherapy (ACE inhibitor) or combination therapy (ACE inhibitor plus the diuretic indapamide). The combination (reducing blood pressure by an average of 12/5 mm Hg) resulted in a 43% (95% CI, 30%-54%) reduction in risk for recurrent stroke in both the hypertensive and normotensive groups. However, no significant benefit was observed when the ACE inhibitor was given alone. Based on these data, the JNC-7 report concluded that recurrent stroke rates are lowered by the combination of an ACE inhibitor and thiazide-type diuretic.6 A preliminary Phase II study randomized 342 hypertensive patients with acute ischemic stroke to an ARB or placebo over the first week.33 No significant differences in blood pressure between the active-treatment and placebo patients were found, and both groups received the ARB after the first week. Although the number of vascular events within the ARB group was significantly reduced during the first week (odds ratio [OR], 0.475; 95% CI, 0.252-0.895), no differences in outcome were found at 3 months. At 12 months, a significant reduction in mortality was observed in the ARB group. The mechanisms by which an acute treatment led to this difference at 12 months, but no difference at 3 months, are uncertain; further studies are needed. Based on these data, guidelines issued jointly by the AHA and ASA recommend antihypertensive treatment for the secondary prevention of stroke once patients are beyond the hyperacute period.29 Because this benefit extends to persons with and without a history of hypertension, the recommendation should be considered for all patients with a history of ischemic stroke or TIA. An absolute target blood pressure
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Diagnosis of hypertensive crisis (SBP >240/130 mm Hg or elevated BP with chest pain, headache, heart failure)
Blood pressure reduction (consider arterial line insertion for continuous BP monitoring)
Initial drug choices
SBP >240/130 mm Hg without symptoms or with headache Nitroprusside I.V. 0.1 mcg/kg/min; increase q3 to 5 min until desired effect (maximum: 5 mcg/kg/min) Or, fenoldopam I.V. 0.05-1.6 mcg/kg/min Or, labetalol 20 mg I.V.; repeat injection q10 minutes prn to maximum dose (300 mg)
Figure 2. Algorithm for the management of hypertensive emergencies.

AHT, antihypertensives; BP, blood pressure; SBP, systolic blood pressure Adapted from reference 6
level and reduction are uncertain and should be individualized, but benefit has been associated with an average reduction of 10/5 mm Hg, and normal blood pressure levels have been defined as below 120/80 mm Hg by JNC-7. The optimal
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Elevated BP with chest pain or heart failure Nitroglycerin I.V. 20-200 mcg/min
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Or, nicardipine I.V. 5-15 mg/h Or, enaliprilat 1.25-5 mg I.V. q6h
Elevated BP in pregnant woman with preeclampsia Hydralazine 5-10 mg I.V. q20 min to maximum dose (20 mg) Or, labetalol 20 mg I.V. followed by 40 mg I.V. 10 min later; then, 80-mg doses q10 min for 2 additional doses to maximum dose (220 mg)
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Begin oral AHT when BP reaches satisfactory level
drug regimen remains uncertain; however, the available data support the use of diuretics or the combination of diuretics and an ACEI.
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Table 5. The Ideal Parenteral Hypertensive

Preserves glomerular filtration rate and renal blood flow Has few, if any, drug interactions (particularly with anesthetics and vasoactive agents) Has little or no potential for exacerbation of comorbid conditions (eg, CHF, COPD) Features rapid onset/offset action
Has minimal hypotension (overshoot)
Incurs minimal need for continuous blood pressure monitoring and frequent dose titration Has no acute tolerance or tachyphylaxis to pharmacodynamic effect
Is easy to use and convenient Is safe and has no toxic metabolites Is low cost (drug and monitoring costs)
Is available in multiple formulations for shortand long-term use Has minimal sympathetic activation
CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease Adapted from reference 36
Section III. Management of Hypertensive Emergencies
Acute cerebrovascular diseases, when accompanied by blood pressure elevation, fall under the general category of hypertensive emergencies. Hypertensive emergencies are characterized by severe elevations in blood pressure (DBP >120 mm Hg) and evidence of impending or progressive target-organ dysfunction.37 The most prevalent associated complications are acute cerebrovascular syndromessuch as cerebral infarction, hypertensive encephalopathy, and ICH or subarachnoid hemorrhage (SAH)but hypertensive emergencies can also manifest as acute coronary syndromes, heart
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failure, pulmonary edema, aortic dissection, hypertensive retinopathy, eclampsia, or acute glomerulonephritis.35 Patients with hypertensive emergencies require an immediate reduction of their blood pressure to prevent or limit target-organ damage. Early triage to establish the appropriate therapeutic strategies for these patients is critical to limiting morbidity and mortality. Those with hypertensive emergencies should be admitted to an intensive care unit for continuous monitoring of blood pressure and parenteral administration of an appropriate agent.6 Figure 2 offers a suggested approach to the management of hypertensive emergencies.6 The initial goal of therapy is to reduce the mean arterial blood pressure by no more than 25%; then, if stable, it should be reduced to 160/100 mm Hg or 160/110 mm Hg within the next 2 to 6 hours. Avoid excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia. If this level of blood pressure is well tolerated and the patient is clinically stable, further gradual reductions can be implemented. Exceptions to the above recommendation include the following: patients with ischemic stroke, in whom no clear evidence from clinical trials supports the use of immediate antihypertensive treatment; patients with aortic dissection, whose SBP should be lowered to below 100 mm Hg if tolerated; and patients whose blood pressure is being lowered to enable the use of thrombolytic agents.6 Blood pressure control is best achieved by using pharmacologic agents that can be readily titrated to prevent hypotension, which can lead to hypoperfusion and organ injury. The agent of choice should have a rapid onset and offset of action and predictable effects, and it should be available in both I.V. and oral forms to facilitate the transition toward hospital discharge. Optimal drugs are those to which tolerance does not develop and that do not cause major drug interactions (Table 5). Direct and indirect costs of the drug are also an important factor; for example, although nitroprusside is inexpensive, the requirement for continuous arterial blood pressure monitoring and volume administration for associated venous dilation must be added to the total cost of drug administration.36 Parental therapy is preferred initially (Table 6). A number of parenteral agents are effective in treating hypertensive
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Table 6. Parenteral Agents for the Treatment of Hypertensive Emergencies

Drug Vasodilators Enalaprilat 1.25-5 mg every 6 h I.V. 15-30 min 6-12 h Acute left ventricular failure; avoid in acute myocardial infarction Dose Onset of Action Duration of Action Special Indications
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Fenoldopam mesylate
0.1-0.3 mcg/kg per min I.V. infusion
<5 min
30 min
Most hypertensive emergencies; caution with glaucoma Eclampsia
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Hydralazine 10-20 mg I.V. hydrochloride 10-40 mg IM Nicardipine 5-15 mg/h I.V. hydrochloride
10-20 min I.V. 20-30 min IM
1-4 h I.V. 4-6 h IM
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15-30 min, Most hypertensive emergencies except acute may heart failure; caution with coronary ischemia exceed 4h 5-10 min Coronary ischemia
Nitroglycerin
5-100 mcg/min as I.V. infusion
2-5 min
Sodium nitroprusside
0.25-10 mcg/kg/min as I.V. infusion
Immediate
1-2 min
Most hypertensive emergencies; caution with high intracranial pressure or azotemia
Adrenergic inhibitors
Esmolol 250-500 mcg/kg/min 1-2 min hydrochloride I.V. bolus, then 50-100 mcg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to 300 mcg/min
10-30 min
Aortic dissection, perioperative
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Table 6. Parenteral Agents for the Treatment of Hypertensive Emergencies

Drug Dose Onset of Action Duration of Action Special Indications
(continued)
Adrenergic inhibitors (continued) Labetalol 20-80 mg I.V. bolus hydrochloride every 10 min 0.52.0 mg/min I.V. infusion 5-10 min 3-6 h Most hypertensive emergencies except acute heart failure
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Phentolamine
5-15 mg I.V. bolus
1-2 min
10-30 min
Catecholamine excess
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* Hypotension may occur with all agents. Adapted from references 6 and 37
emergencies. Labetalol is effective when administered as a 20- to 80-mg bolus I.V. injection and can provide a stepwise, controlled reduction in blood pressure to a predetermined goal. Once the goal blood pressure is achieved, injections are stopped, and the long duration of action facilitates conversion to effective oral therapy.37,38 A continuous infusion of labetalol at 2 mg per minute is an alternative method of administration and also provides a gradual yet controlled reduction in blood pressure. Because the -blocking effects of this agent predominate, bradycardia or heart block may be observed in patients with intrinsic heart disease. Sodium nitroprusside has an extremely rapid onset of action, within seconds after the initiation of an infusion, and a rapid offset of effect, within 1 to 2 minutes, which necessitates constant supervision of blood pressure during administration. This agent is particularly effective in reducing preload and afterload in patients with impaired left ventricular function, and a carefully titrated infusion can achieve any desired goal blood pressure. Nitroprusside does not cause sedation or somnolence but is rapidly degraded by light, so that a periodic exchange of solutions is required. In patients with significant renal impairment, a major metabolite, thiocyanate, may accumulate over several days with toxic effects.39
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Nicardipine is an I.V. form of the dihydropyridine calcium antagonist and is effective in a high percentage of hypertensive emergencies, particularly at higher infusion rates.40 However, it should not be used in cases of acute heart failure due to the potential for tachycardia.34 Nicardipine is easy to administer. Infusion rates can be increased by 2.5 mg per hour at intervals of 15 minutes until the maximal recommended dose of 15 mg per hour is obtained or the desired reduction in blood pressure is achieved. Dosing of nicardipine is not dependent on body weight. Nicardipine has been shown to reduce both cerebral and coronary ischemia.
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Section IV. Treatment of Acute Ischemic Stroke
Despite the prevalence of arterial hypertension following stroke, its optimal management has not been established. An elevated blood pressure can result from a physiologic response to brain injury, agitation, pain, preexisting hypertension, or increased intracranial pressure (ICP). Theoretical reasons to lower the blood pressure include reducing brain edema, lessening the risk for hemorrhagic transformation of the infarction, preventing further vascular damage, and forestalling early recurrent stroke. However, aggressive treatment of elevated blood pressure can be detrimental because of the
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Table 7. AHA/ASA Guidelines for the Management of Arterial Hypertension in Acute Ischemic Stroke
Blood pressure level
Not eligible for thrombolytic therapy: systolic 220 OR diastolic 120
Treatment
Observe unless other end-organ involvement (eg, aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive encephalopathy) Treat other symptoms of stroke (eg, headache, pain, agitation, nausea, vomiting) Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia Labetalol 1020 mg I.V. for 12 min May repeat or double every 10 min (max dose 300 mg) OR nicardipine 5 mg/h I.V. infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to max of 15 mg/h Aim for a 10%15% reduction in blood pressure Nitroprusside 0.5 gkg1min1 I.V. infusion as initial dose with continuous blood pressure monitoring Aim for a 10%15% reduction in blood pressure Labetalol 1020 mg I.V. for 12 min May repeat 1 time or nitropaste 12 min
Not eligible for thrombolytic therapy: systolic >220 OR diastolic 121140
Not eligible for thrombolytic therapy: diastolic >140
Eligible for thrombolytic therapy (Pretreatment) systolic >185 OR diastolic >110 Eligible for thrombolytic therapy (during/after treatment) 1. Monitor blood pressure 2. Diastolic 140 3. Systolic >230 OR diastolic 121140
4. Systolic 180230 OR diastolic 105120
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1. Check blood pressure every 15 min for 2 h, then every 30 min for 6 h, and finally every hour for 16 h 2. Sodium nitroprusside 0.5 gkg1min1 I.V. infusion as initial dose and titrate to desired blood pressure 3. Labetalol 10 mg I.V. for 12 min May repeat or double labetalol every 10 min to maximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 28 mg/min OR nicardipine 5 mg/h I.V. infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15 mg/h; if blood pressure is not controlled by labetalol, consider sodium nitroprusside 4. Labetalol 10 mg I.V. for 12 min May repeat or double labetalol every 1020 min to maximum dose of 300 mg or give initial labetalol dose, then start labetalol drip at 28 mg/min
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Table 8. Recommended Guidelines for Treating Elevated Blood Pressure in Spontaneous ICH
1. If SBP is >200 mm Hg or MAP is >150 mm Hg, then consider aggressive reduction of blood pressure with continuous I.V. infusion, with frequent blood pressure monitoring every 5 min. 2. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous I.V. medications to keep cerebral perfusion pressure >60-80 mm Hg. 3. If SBP is >180 mm Hg or MAP is >130 mm Hg and there is no evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (eg, MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous I.V. medications to control blood pressure, and clinically reexamine the patient every 15 min.
Table 9. I.V. Medications for Control of Elevated Blood Pressure in Patients With ICH
Drug Enalapril I.V. Bolus Dose 1.25-5 mg IVP every 6 h* 250 mcg/kg IVP loading dose 5-20 mg IVP every 30 min 5-20 mg every 15 min NA Continuous Infusion Rate NA
ICH, intracerebral hemorrhage; ICP, intracranial pressure; MAP, mean arterial pressure; SBP, systolic blood pressure Adapted from reference 52
secondary reduction of perfusion in the area of ischemia, which can expand the infarction.41 Because of these conflicting issues and the lack of reliable data, the appropriate management of the blood pressure in the setting of acute ischemic stroke remains controversial. In a majority of patients, the blood pressure will decline without any specific medical treatment.41 Blood pressure often falls spontaneously when the patient is moved to a quiet room, the bladder is emptied, pain is controlled, and the patient is allowed to rest. In addition, treatment to reduce increased ICP can result in a decline in arterial blood pressure. Although no definitive data from controlled clinical trials are available, in the absence of other organ dysfunction necessitating a rapid reduction in blood pressure, or unless
30
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Esmolol
25-300 mcgkg-1min-1
Hydralazine
1.5-5 mcgkg-1min-1
Labetalol
2 mg/min (maximum 300 mg/d) 5 to 15 mg/h
Nicardipine

Nitroglycerin NA Sodium NA nitroprusside
20-400 mcg/min
0.1-10 mcgkg-1min-1
ICH, intracerebral hemorrhage; IVP, intravenous push; NA, not applicable.
*Because of the risk of precipitous blood pressure lowering, the enalapril first test dose should be 0.625 mg.
thrombolytic therapy is being administered, there is little scientific basis and no clinically proven benefit for lowering the blood pressure of patients with acute ischemic stroke41 and some investigators report that lowering blood pressure in patients with acute ischemic stroke can be harmful.42 The few studies that have addressed this issue offer conflicting data. One placebo-controlled Phase II safety trial tested the utility of administering candesartan to hypertensive patients with acute ischemic stroke.33 At 12 months, patients treated with candesartan had improved survival and few subsequent vascular events. No differences in blood pressure values were noted, however, and the effects on the outcome of the
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stroke were not described. INWEST (Intravenous Nimodipine [Nimotop, Bayer] West European Trial) was designed to test the potential efficacy of nimodipine infused intravenously as a neuroprotetive agent.43 This study had to be stopped because of a clear detrimental effect on outcome that was related to the degree of reduction in DBP. Although severe hypertension might be considered an indication for treatment, no data are available to define the levels of arterial hypertension that mandate emergent management.41 Thus, in most circumstances, the blood pressure should be carefully monitored but not lowered within the first 12 to 24 hours after stroke onset. The 2007 guidelines from the AHA/ASA on the management of acute ischemic stroke suggest that antihypertensive agents should be withheld unless the DBP is above 120 mm Hg or unless the SBP is above 220 mm Hg (Table 7).17,44 By contrast, situations that might require urgent antihypertensive therapy include concomitant hypertensive encephalopathy, aortic dissection, acute renal failure, acute pulmonary edema, and acute myocardial ischemia.34 Among patients who are candidates for treatment with thrombolytic agents, careful management of blood pressure is critical before and during their administration and during the ensuing 24 hours because excessively high blood pressure is associated with parenchymal hemorrhage.45,46 Thrombolytic therapy is not given to patients who have an SBP above 185 mm Hg or a DBP above 110 mm Hg.17 When treatment is indicated, the blood pressure should be lowered carefully. Continuously infused parenteral agents such as labetalol and nicardipine are easily titrated and preferred for the treatment of hypertension in the acute setting because they can more precisely maintain a target blood pressure than oral agents. Sodium nitroprusside is recommended only for severe hypertension and should be used with caution because of its tendency to overshoot and cause excessive drops in blood pressure, particularly in patients who are dehydrated.41 In other situations, an oral agent, such as captopril or metoprolol, can be used when precise control of the blood pressure is not essential.17 The sublingual administration of a calcium antagonist, such as nifedipine, should be avoided because of rapid absorption and a secondary precipitous decline in blood pressure.47 Although there are no definitive data to guide the precise
Table 10. 1994 AHA Guidelines on the Management of Subarachnoid Hemorrhage

Recommendations The relationship between hypertension and SAH is uncertain (level of evidence III to IV, grade C). Antihypertensive therapy alone is not recommended to prevent rebleeding after SAH, although it is frequently included in the overall treatment of patients with SAH (level of evidence I to HI, grade B).
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SAH, subarachnoid hemorrhage Adapted from reference 59
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timing of initiation or reinitiation of antihypertensive therapy following stroke, the 2007 ASA guidelines indicate that most patients with mild to moderate strokes (and not at high risk for increased ICP) may have their prestroke antihypertensive medications reinitiated approximately 24 hours after their vascular event.17 Furthermore, the ACCESS trial reported favorable safety data when candesartan was started 1 day after stroke.33 Regardless, decisions regarding the precise timing of initiation or reinitiation of antihypertensive therapy following stroke must be determined on an individualized basis and take into account the patients neurologic status, the underlying stroke mechanism, the patients ability to swallow medications, and the presence of concomitant diseases.
Section V. Treatment of Hemorrhagic Stroke

Intracerebral Hemorrhage
Advancing age and hypertension are the most important risk factors for ICH.48 Well-designed and well-executed randomized treatment studies for the secondary prevention of ICH are relatively scarce. In an analysis of multiple trials by Collins and colleagues, an average reduction in DBP of 6 mm Hg by antihypertensive medication produced an aggregate 42% reduction in the
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incidence of stroke, including hemorrhagic stroke.49 SHEP reported that treatment of isolated systolic hypertension in the elderly decreased the risk for ICH by 50%.50 Despite the lack of conclusive evidence, these intervention studies and the high prevalence of hypertension in persons with ICH indicate that treatment of hypertension is probably effective in reducing the incidence of ICH. In patients with acute ICH, the optimal level of a patients blood pressure should be determined based on individual factors such as chronic hypertension, elevated ICP, age, presumed cause of hemorrhage, and interval since onset. In general, recommendations for the treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke. The theoretical rationale for lowering blood pressure is to decrease the risk for ongoing bleeding from ruptured small arteries and arterioles. A prospective observational study of growth in the volume of ICH did not demonstrate a relationship between baseline blood pressure and subsequent growth of ICH, but frequent early use of hypertensive agents in this study may have obscured any relationship.51 Conversely, overaggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury, particularly in the setting of increased ICP. To balance these 2 theoretical rationales, the AHA Stroke Council issued guidelines in 2007 for the management of ICH (Tables 8 and 9).52 They recommend that patients with ICH and a mean or systolic arterial blood pressure of greater than 130 mm Hg and 180 mm Hg, respectively, undergo antihypertensive treatment to achieve a mean arterial blood pressure of 110 mm Hg or a systolic/diastolic blood pressure below 160/90 mm Hg. They also state that aggressive antihypertensive therapy should be instituted for those patients with ICH and a mean arterial blood pressure greater than 150 mm Hg or an SBP greater than 200 mm Hg, but do not provide target blood pressure goals. Furthermore, in patients with elevated ICP who have an ICP monitor, the cerebral perfusion pressure should be kept above 60 to 80 mm Hg. These guidelines acknowledge the fact that these recommendations are based on incomplete evidence and suggest that data from the ongoing ATACH (Antihypertensive Treatment in Acute Cerebral Hemorrhage) pilot study and the Phase III random-
ized international INTERACT (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage) study will likely provide high-level data to help guide future revisions. Parenteral agents commonly used for the reduction of blood pressure in patients with ICH include labetalol and nicardipine (Table 9).52
Subarachnoid Hemorrhage
Subarachnoid hemorrhage (SAH) is a common and often devastating occurrence. Despite considerable advances in diagnostic, surgical, and anesthetic techniques and perioperative management, the outcome for patients with SAH remains poor.53 Although hypertension is a common and important risk factor for ICH, it does not appear to be as important a risk factor for SAH events. The evidence that antihypertensive medications have a beneficial effect on the incidence of SAH has been anecdotal. Nevertheless, although blood pressure control in the general population has improved markedly in the past decade, the incidence of SAH during that time has changed little.54 Based on available data, the AHA states that the relationship between hypertension and SAH is uncertain. Preventing aneurysm rebleeding with antihypertensive medications remains controversial. In a randomized trial of antihypertensive and antifibrinolytic agents, Nibbelink found that rebleeding was higher in groups treated with antihypertensive agents, although rebleeding in these patients was likely related to the existence of hypertension rather than its treatment.55 In the randomized treatment study of Torner et al,56 no difference was noted between conservative bed rest and antihypertensive therapy. In an observational study by Wijdicks and colleagues,57 the rate of rebleeding was higher in patients who did not receive antihypertensive therapy, despite lower blood pressures in this group, than in patients treated with antihypertensive agents. Rebleeding may be related to variations or changes in blood pressure rather than to absolute blood pressure.58 Based on these data, the 1994 AHA guidelines state that antihypertensive therapy alone is not recommended to prevent rebleeding after SAH, although it is frequently included in the overall treatment of patients with SAH (Table 10).59
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Section VI: Management of Hypertension in the Setting of Elevated Intracranial Pressure

Intracranial hemorrhage and large hemispheric infarction are often complicated by the development of elevated ICP and secondary cerebral edema, which are associated with higher rates of mortality. Elevated ICP is typically medically managed with sedation, osmotherapy, controlled hyperventilation, and barbiturate coma.52 However, concomitant hypertension can sometimes overwhelm normal cerebral autoregulatory mechanisms and exacerbate the effects of elevated ICP and cerebral edema, whereas hypotension may worsen ischemic damage in marginally perfused tissue. Thus, the continuous infusion of short-acting agents with reliable doseresponse relationships and favorable safety profilesincluding labetalol, esmolol, and nicardipineis desirable for the control of extreme hypertension in patients with elevated ICP.60 There is a paucity of randomized controlled trials to determine appropriate blood pressure targets, but recommendations for blood pressure control in patients with elevated ICP closely mirror those for control of blood pressure in patients with ICH.52
2006;295:180-189. 8. ALLHAT Investigators. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-2997. National Heart, Lung, and Blood Institute. Strong Heart Study Data Book: a Report to American Indians Communities. Bethesda, Md: National Institutes of Health, National Heart, Lung, and Blood Institute; 2001:19. NIH Publication No. 01-3285.
9.
10. Crespo CJ, Loria CM, Burt VL. Hypertension and Other Cardiovascular Disease Risk Factors Among Mexican Americans, Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey. Public Health Report. 1996;111:7-10. 11. Jamerson K, DeQuattro V. The impact of ethnicity on response to antihypertensive therapy. Am J Med. 1996;101:22S-32S.
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12. Saunders E, Weir MR, Kong BW, et al. A comparison of the efficacy and safety of a beta-blocker, a calcium channel blocker, and a converting enzyme inhibitor in hypertensive blacks. Arch Intern Med. 1990;150:1707-1713. 13. Cushman WC, Reda DJ, Perry HM, Williams D, Abdellatif M, Materson BJ. Regional and racial differences in response to antihypertensive medication use in a randomized controlled trial of men with hypertension in the United States. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med. 2000;160:825-831. 14. American Heart Association. Heart Disease and Stroke Statistics2004 Update. Dallas, Texas: American Heart Association; 2003. 15. Howard G, Howard VJ, Katholi C, Oli MK, Huston S. Decline in US stroke mortality: an analysis of temporal patterns by sex, race, and geographic region. Stroke. 2001;32:2213-2220. 16. Brown RD, Whisnant JP, Sicks JD, OFallon WM, Wiebers DO. Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989. Stroke. 1996;27:373-380. 17. Adams H, Del Zoppo G, Alberts MJ; Stroke Council of the American Heart Association; American Stroke Assocation. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655-1711. 18. Gorelick PB. Stroke prevention. Arch Neurol. 1995;52:347-355. 19. Rothwell PM, Coull AJ, Giles MF, et al; Oxford Vascular Study. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK, from 1981 to 2004 (Oxford Vascular Study). Lancet. 2004;363:1925-1933.
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47. Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA. 1996;276:1328-1331. 48. Broderick J. Intracerebral hemorrhage. In: Gorelick PB, Alter M, eds. Handbook of Neuroepidemiology. New York, NY: Marcel Dekker, Inc; 1994:141-167. 49. Collins R, Peto R, MacMahon S, et al. Blood pressure, stroke, and coronary heart disease, II: short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet. 1990;335:827-838. 50. SHEP Cooperative Research Group. Prevention of various stroke types by treatment of isolated systolic hypertension. Presented at: International Stroke Society 2nd World Stroke Congress; Washington, DC; September 1992. 51. Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997;28:1-5. 52. Broderick J, Connolly S, Feldmann E, et al.. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38:2001-2023. 53. Ingall TJ, Wiebers DO. Natural history of subarachnoid hemorrhage. In: Whisnant JP, ed. Stroke: Populations, Cohorts, and Clinical Trials. Boston, Mass: Butterworth-Heinemann; 1993.
55. Nibbelink DW. Antihypertensive and antifibrinolytic therapy following subarachnoid hemorrhage from ruptured intracranial aneurysm. In: Sahs AL, Nibbelink DW, Torner JC, eds. Aneurysmal Subarachnoid Hemorrhage: Report of the Cooperative Study. Baltimore, MD: Urban & Schwarzenberg; 1981:287-296. 56. Torner JC, Nibbelink DW, Burmeister LF. Statistical comparisons of end results of a randomized treatment study. In: Sahs AL, Nibbelink DW, Torner JC, eds. Aneurysmal Subarachnoid Hemorrhage: Report of the Cooperative Study. Baltimore, MD: Urban & Schwarzenberg; 1981:249-276. 57. Wijdicks EF, Vermeulen M, Murray GD, Hijdra A, van Gijn J. The effects of treating hypertension following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg. 1990;92:111-117. 58. Stornelli SA, French JD. Subarachnoid hemorrhage factors in prognosis and management. J Neurosurg. 1964;21:769-781. 59. Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation. 1994;90:2592-2605. 60. Rose JC, Mayer SA. Optimizing blood pressure in neurological emergencies. Neurocrit Care. 2004;1:287-299.
54. Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1994;25:2315-2328.
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Important Safety Information
Close monitoring of the blood pressure is required during therapy. Most common side effects of CARDENE I.V. are headache (14.6%), hypotension (5.6%), nausea/vomiting (4.9%), and tachycardia (3.5%). Less frequent adverse effects, in each case occurring at 1.4%, include ECG abnormalities, postural hypotension, ventricular extrasystoles, injection-site reaction, dizziness, sweating, and polyuria. CARDENE I.V. is contraindicated in patients with known hypersensitivity to the drug and those with advanced aortic stenosis. Caution is advised when administering CARDENE I.V. to patients with impaired renal or hepatic function, in combination with a -blocker in patients with CHF, and in patients with significant left ventricular dysfunction or portal hypertension. CARDENE I.V. gives no protection against the dangers of abrupt -blocker withdrawal. -blocker dosage should be gradually reduced. Levels of cyclosporine should be closely monitored during therapy. Observe caution in patients with severe left ventricular dysfunction due to possible negative inotropic effect. Please see full prescribing information.
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CARDENE I.V. (nicardipine hydrochloride) Coronary steal has not been observed during treatment with Cardene I.V. (Coronary steal is the detrimental redistribution of coronary blood ow in patients with coronary artery disease from underperfused areas toward better perfused areas.) Cardene I.V. has been shown to improve systolic shortening in both normal and hypokinetic segments of myocardial muscle. Radionuclide angiography has conrmed that wall motion remained improved during increased oxygen demand. (Occasional patients have developed increased angina upon receiving Cardene capsules. Whether this represents coronary steal in these patients, or is the result of increased heart rate and decreased diastolic pressure, is not clear.) In patients with coronary artery disease, Cardene I.V. improves left ventricular diastolic distensibility during the early lling phase, probably due to a faster rate of myocardial relaxation in previously underperfused areas. There is little or no effect on normal myocardium, suggesting the improvement is mainly by indirect mechanisms such as afterload reduction and reduced ischemia. Cardene I.V. has no negative effect on myocardial relaxation at therapeutic doses. The clinical benets of these properties have not yet been demonstrated. resistance; glomerular ltration rate (GFR), renal plasma ow (RPF), and the ltration fraction were unchanged. In healthy patients undergoing abdominal surgery, Cardene I.V. (10 mg over 20 minutes) increased GFR with no change in RPF when compared with placebo. In hypertensive type ll diabetic patients with nephropathy, Cardene capsules (20 mg TID) did not change RPF and GFR, but reduced renal vascular resistance.
Rx Only
DESCRIPTION
Cardene (nicardipine HCI) is a calcium ion inux inhibitor (slow channel blocker or calcium channel blocker). Cardene I.V. for intravenous administration contains 2.5 mg/mL of nicardipine hydrochloride. Nicardipine hydrochloride is a dihydropyridine derivative with IUPAC (International Union of Pure and Applied Chemistry) chemical name ()-2-(benzyl-methyl amino) ethyl methyl 1,4dihydro-2,6-dimethyl-4-(m-nitro-phenyl)-3,5-pyridinedicarboxylate monohydrochloride and has the following structure:
Nicardipine hydrochloride is a greenish-yellow, odorless, crystalline powder that melts at about 169 C. It is freely soluble in chloroform, methanol, and glacial acetic acid, sparingly soluble in anhydrous ethanol, slightly soluble in n-butanol, water, 0.01 M potassium dihydrogen phosphate, acetone, and dioxane, very slightly soluble in ethyl acetate, and practically insoluble in benzene, ether, and hexane. It has a molecular weight of 515.99. Cardene l.V. is available as a sterile, non-pyrogenic, clear, yellow solution in 10 mL ampuls for intravenous infusion after dilution. Each mL contains 2.5 mg nicardipine hydrochloride in Water for Injection, USP with 48.00 mg Sorbitol, NF, buffered to pH 3.5 with 0.525 mg citric acid monohydrate, USP and 0.09 mg sodium hydroxide, NF. Additional citric acid and/or sodium hydroxide may have been added to adjust pH.
Rapid dose-related increases in nicardipine plasma concentrations are seen during the rst two hours after the start of an infusion of Cardene I.V. Plasma concentrations increase at a much slower rate after the rst few hours, and approach steady state at 24 to 48 hours. On termination of the infusion, nicardipine concentrations decrease rapidly, with at least a 50% decrease during the rst two hours post-infusion. The effects of nicardipine on blood pressure signicantly correlate with plasma concentrations. Nicardipine is highly protein bound (95%) in human plasma over a wide concentration range. Cardene I.V. has been shown to be rapidly and extensively metabolized by the liver. After coadministration of a radioactive intravenous dose of Cardene I.V. with an oral 30 mg dose given every 8 hours, 49% of the radioactivity was recovered in the urine and 43% in the feces within 96 hours. None of the dose was recovered as unchanged nicardipine. Nicardipine does not induce or inhibit its own metabolism and does not induce or inhibit hepatic microsomal enzymes. The steady-state pharmacokinetics of nicardipine are similar in elderly hypertensive patients (65 years) and young healthy adults.
Pulmonary Function
In two well-controlled studies of patients with obstructive airway disease treated with Cardene capsules, no evidence of increased bronchospasm was seen. In one of the studies, Cardene capsules improved forced expiratory volume 1 second (FEV1) and forced vital capacity (FVC) in comparison with metoprolol. Adverse experiences reported in a limited number of patients with asthma, reactive airway disease, or obstructive airway disease are similar to all patients treated with Cardene capsules.
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Hemodynamics
Cardene I.V. produces signicant decreases in systemic vascular resistance. In a study of intra-arterially administered Cardene I.V., the degree of vasodilation and the resultant decrease in blood pressure were more prominent in hypertensive patients than in normotensive volunteers. Administration of Cardene I.V. to normotensive volunteers at dosages of 0.25 to 3.0 mg/hr for eight hours produced changes of 5 mmHg in systolic blood pressure and 3 mmHg in diastolic blood pressure. An increase in heart rate is a normal response to vasodilation and decrease in blood pressure; in some patients these increases in heart rate may be pronounced. In placebocontrolled trials, the mean increases in heart rate were 7 1 bpm in postoperative patients and 8 1 bpm in patients with severe hypertension at the end of the maintenance period.
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Effects in Hypertension
In patients with mild-to-moderate chronic stable essential hypertension, Cardene I.V. (0.5 to 4.0 mg/hr) produced dosedependent decreases in blood pressure, although only the decreases at 4.0 mg/hr were statistically different from placebo. At the end of a 48-hour infusion at 4.0 mg/hr, the decreases were 26.0 mmHg (17%) in systolic blood pressure and 20.7 mmHg (20%) in diastolic blood pressure. In other settings (e.g., patients with severe or postoperative hypertension), Cardene I.V. (5 to 15 mg/hr) produced dosedependent decreases in blood pressure. Higher infusion rates produced therapeutic responses more rapidly. The mean time to therapeutic response for severe hypertension, dened as diastolic blood pressure 95 mmHg or 25 mmHg decrease and systolic blood pressure 160 mmHg, was 77 5.2 minutes. The average maintenance dose was 8.0 mg/hr. The mean time to therapeutic response for postoperative hypertension, dened as 15% reduction in diastolic or systolic blood pressure, was 11.5 0.8 minutes. The average maintenance dose was 3.0 mg/hr.
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Electrophysiologic Effects

In general, no detrimental effects on the cardiac conduction system have been seen with Cardene I.V. During acute electrophysiologic studies, it increased heart rate and prolonged the corrected QT interval to a minor degree. It did not affect sinus node recovery or SA conduction times. The PA, AH, and HV intervals* or the functional and effective refractory periods of the atrium were not prolonged. The relative and effective refractory periods of the His-Purkinje system were slightly shortened.
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Hepatic Function
CLINICAL PHARMACOLOGY Mechanism of Action

Nicardipine inhibits the transmembrane inux of calcium ions into cardiac muscle and smooth muscle without changing serum calcium concentrations. The contractile processes of cardiac muscle and vascular smooth muscle are dependent upon the movement of extracellular calcium ions into these cells through specic ion channels. The effects of nicardipine are more selective to vascular smooth muscle than cardiac muscle. In animal models, nicardipine produced relaxation of coronary vascular smooth muscle at drug levels which cause little or no negative inotropic effect.
Because nicardipine is extensively metabolized by the liver, plasma concentrations are inuenced by changes in hepatic function. In a clinical study with Cardene capsules in patients with severe liver disease, plasma concentrations were elevated and the half-life was prolonged (see Precautions). Similar results were obtained in patients with hepatic disease when Cardene I.V. (nicardipine hydrochloride) was administered for 24 hours at 0.6 mg/hr.
INDICATION AND USAGE

Cardene I.V. is indicated for the short-term treatment of hypertension when oral therapy is not feasible or not desirable. For prolonged control of blood pressure, patients should be transferred to oral medication as soon as their clinical condition permits (see Dosage and Administration).
Renal Function
Pharmacokinetics and Metabolism

Following infusion, nicardipine plasma concentrations decline tri-exponentially, with a rapid early distribution phase (-halflife of 2.7 minutes), an intermediate phase (-half-life of 44.8 minutes), and a slow terminal phase (-half-life of 14.4 hours) that can only be detected after long-term infusions. Total plasma clearance (Cl) is 0.4 L/hrkg, and the apparent volume of distribution (Vd) using a non-compartment model is 8.3 L/kg. The pharmacokinetics of Cardene l.V. are linear over the dosage range of 0.5 to 40.0 mg/hr.
Hemodynamic studies following intravenous dosing in patients with coronary artery disease and normal or moderately abnormal left ventricular function have shown signicant increases in ejection fraction and cardiac output with no significant change, or a small decrease, in left ventricular end-diastolic pressure (LVEDP). There is evidence that Cardene increases blood ow. Coronary dilatation induced by Cardene I.V. improves perfusion and aerobic metabolism in areas with chronic ischemia, resulting in reduced lactate production and augmented oxygen consumption. In patients with coronary artery disease, Cardene I.V., administered after beta-blockade, signicantly improved systolic and diastolic left ventricular function.
When Cardene I.V. was given to mild-to-moderate hypertensive patients with moderate degrees of renal impairment, signicant reduction in glomerular ltration rate (GFR) and effective renal plasma ow (RPF) was observed. No signicant differences in liver blood ow were observed in these patients. A signicantly lower systemic clearance and higher area under the curve (AUC) were observed.
CONTRAINDICATIONS
Cardene I.V. is contraindicated in patients with known hypersensitivity to the drug. Cardene I.V. is also contraindicated in patients with advanced aortic stenosis because part of the effect of Cardene I.V. is secondary to reduced afterload. Reduction of diastolic pressure in these patients may worsen rather than improve myocardial oxygen balance.
When Cardene capsules (20 mg or 30 mg TID) were given to hypertensive patients with impaired renal function, mean plasma concentrations, AUC, and Cmax were approximately twofold higher than in healthy controls. There is a transient increase in electrolyte excretion, including sodium (see Precautions).
In congestive heart failure patients with impaired left ventricular function, Cardene I.V. increased cardiac output both at rest and during exercise. Decreases in left ventricular end-diastolic pressure were also observed. However, in some patients with severe left ventricular dysfunction, it may have a negative inotropic effect and could lead to worsened failure.
Acute bolus administration of Cardene I.V. (2.5 mg) in healthy volunteers decreased mean arterial pressure and renal vascular
* PA = conduction time from high to low right atrium; AH = conduction time from low right atrium to His bundle deection, or AV nodal conduction time; HV = conduction time through the His bundle and the bundle branch-Purkinje system.
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WARNINGS Beta-Blocker Withdrawal

Nicardipine is not a beta-blocker and therefore gives no protection against the dangers of abrupt beta-blocker withdrawal; any such withdrawal should be by gradual reduction of dose of beta-blocker.
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CARDENE I.V. (nicardipine hydrochloride)
CARDENE I.V. (nicardipine hydrochloride) treated with up to 25 mg nicardipine/kg/day for one year and no evidence of effects of nicardipine on thyroid function (plasma T4 and TSH) in man. There was no evidence of a mutagenic potential of nicardipine in a battery of genotoxicity tests conducted on microbial indicator organisms, in micronucleus tests in mice and hamsters, or in a sister chromatid exchange study in hamsters. No impairment of fertility was seen in male or female rats administered nicardipine at oral doses as high as 100 mg/kg/day (50 times the 40 mg TlD maximum recommended dose in man, assuming a patient weight of 60 kg). Pregnancy Category C: There are no adequate and wellcontrolled studies in pregnant women; Cardene I.V. should be used during pregnancy only if the potential benet justies the potential risk to the fetus. Cardene I.V. administered at doses up to 5 mg/kg/day and up to 0.5 mg/kg/day to pregnant rats and rabbits, respectively, produced no embryotoxicity or teratogenicity. Embryotoxicity, but not teratogenicity, was seen at 10 mg/kg/day in rats and at 1 mg/kg/day in rabbits. Nicardipine was embryocidal at oral doses of 150 mg/kg/day, given during organogenesis, to pregnant white rabbits but not at 50 mg/kg/day (25 times MRHD). No adverse effects on the fetus were observed when albino rabbits were treated, during organogenesis, with up to 100 mg/kg/day of nicardipine. Pregnant rats receiving oral doses up to 100 mg/kg/day (50 times MRHD) showed no evidence of embryolethality or teratogenicity. However, dystocia and reductions in birth weights, neonatal survival, and neonatal weight gain were noted. There are no adequate and well-controlled studies in pregnant women. Cardene should be used in pregnancy only if the potential benet justies the potential risk to the fetus. Percent of Patients with Adverse Experiences During the Double-Blind Portion of Controlled Trials Adverse Experience Body as a Whole Headache Asthenia Abdominal pain Chest pain Cardiovascular Hypotension Tachycardia ECG abnormality Postural hypotension Ventricular extrasystoles Extrasystoles Hemopericardium Hypertension Supraventricular tachycardia Syncope Vasodilation Ventricular tachycardia Digestive Nausea/vomiting Injection Site Injection site reaction Injection site pain Metabolic and Nutritional Hypokalemia Nervous Dizziness Hypesthesia Intracranial hemorrhage Paresthesia Respiratory Dyspnea Skin and Appendages Sweating Urogenital Polyuria Hematuria Cardene (n=144) Placebo (n=100) 14.6 0.7 0.7 0.7 5.6 3.5 1.4 1.4 1.4 0.7 0.7 0.7 0.7 0.7 0.7 0.7 4.9 1.4 0.7 0.7 1.4 0.7 0.7 0.7 0.7 1.4 1.4 0.7 2.0 0.0 0.0 0.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Rapid Decreases in Blood Pressure

No clinical events have been reported suggestive of a too rapid decrease in blood pressure with Cardene I.V. However, as with any antihypertensive agent, blood pressure lowering should be accomplished over as long a time as is compatible with the patients clinical status.
Drug Interactions
Since Cardene I.V. may be administered to patients already being treated with other medications, including other antihypertensive agents, careful monitoring of these patients is necessary to detect and promptly treat any undesired effects from concomitant administration.
Use in Patients with Angina

Increases in frequency, duration, or severity of angina have been seen in chronic oral therapy with Cardene capsules. Induction or exacerbation of angina has been seen in less than 1% of coronary artery disease patients treated with Cardene I.V. The mechanism of this effect has not been established.
Beta-Blockers
In most patients, Cardene I.V. can safely be used concomitantly with beta-blockers. However, caution should be exercised when using Cardene l.V. in combination with a beta-blocker in congestive heart failure patients (see Warnings).
Use in Patients with Congestive Heart Failure

Cardene I.V. reduced afterload without impairing myocardial contractility in preliminary hemodynamic studies of CHF patients. However, in vitro and in some patients, a negative inotropic effect has been observed. Therefore, caution should be exercised when using Cardene I.V., particularly in combination with a beta-blocker, in patients with CHF or signicant left ventricular dysfunction.
Use in Patients with Pheochromocytoma

Only limited clinical experience exists in use of Cardene I.V. for patients with hypertension associated with pheochromocytoma. Caution should therefore be exercised when using the drug in these patients.
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Cimetidine has been shown to increase nicardipine plasma concentrations with Cardene capsule administration. Patients receiving the two drugs concomitantly should be carefully monitored. Data with other histamine-2 antagonists are not available.
Digoxin
Studies have shown that Cardene capsules usually do not alter digoxin plasma concentrations. However, as a precaution, digoxin levels should be evaluated when concomitant therapy with Cardene I.V. is initiated.
Fentanyl Anesthesia
Peripheral Vein Infusion Site

To minimize the risk of peripheral venous irritation, it is recommended that the site of infusion of Cardene I.V. be changed every 12 hours.
Hypotension has been reported during fentanyl anesthesia with concomitant use of a beta-blocker and a calcium channel blocker. Even though such interactions were not seen during clinical studies with Cardene l.V. (nicardipine hydrochloride), an increased volume of circulating uids might be required if such an interaction were to occur.
Cyclosporine PRECAUTIONS General

Blood Pressure: Because Cardene I.V. decreases peripheral resistance, monitoring of blood pressure during administration is required. Cardene I.V., like other calcium channel blockers, may occasionally produce symptomatic hypotension. Caution is advised to avoid systemic hypotension when administering the drug to patients who have sustained an acute cerebral infarction or hemorrhage. Use in Patients with Impaired Hepatic Function: Since nicardipine is metabolized in the liver, the drug should be used with caution in patients with impaired liver function or reduced hepatic blood ow. The use of lower dosages should be considered. Nicardipine administered intravenously has been reported to increase hepatic venous pressure gradient by 4 mmHg in cirrhotic patients at high doses (5 mg/20 min). Cardene I.V. should therefore be used with caution in patients with portal hypertension. Use in Patients with Impaired Renal Function: When Cardene I.V. was given to mild-to-moderate hypertensive patients with moderate renal impairment, a signicantly lower systemic clearance and higher AUC was observed. These results are consistent with those seen after oral administration of nicardipine. Careful dose titration is advised when treating renal impaired patients.
Concomitant administration of capsules and cyclosporine results in elevated plasma cyclosporine levels. Plasma concentrations of cyclosporine should therefore be closely monitored during Cardene I.V. administration, and the dose of cyclosporine reduced accordingly.
In Vitro Interaction
The plasma protein binding of nicardipine was not altered when therapeutic concentrations of furosemide, propranolol, dipyridamole, warfarin, quinidine, or naproxen were added to human plasma in vitro.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Rats treated with nicardipine in the diet (at concentrations calculated to provide daily dosage levels of 5, 15, or 45 mg/kg/day) for two years showed a dose-dependent increase in thyroid hyperplasia and neoplasia (follicular adenoma/carcinoma). Oneand three-month studies in the rat have suggested that these results are linked to a nicardipine-induced reduction in plasma thyroxine (T4) levels with a consequent increase in plasma levels of thyroid stimulating hormone (TSH). Chronic elevation of TSH is known to cause hyperstimulation of the thyroid. In rats on an iodine decient diet, nicardipine administration for one month was associated with thyroid hyperplasia that was prevented by T4 supplementation. Mice treated with nicardipine in the diet (at concentrations calculated to provide daily dosage levels of up to 100 mg/kg/day) for up to 18 months showed no evidence of neoplasia of any tissue and no evidence of thyroid changes. There was no evidence of thyroid pathology in dogs
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Nursing Mothers
Studies in rats have shown signicant concentrations of nicardipine in maternal milk. Therefore, use in nursing mothers is not recommended.
Pediatric Use
Safety and efcacy in patients under the age of 18 have not been established.
Geriatiric Use:
The steady-state pharmacokinetics of nicardipine are similar in elderly hypertensive patients (65 years) and young healthy adults.
Clinical studies of nicardipine did not include sufcient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identied differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.
Rare Events
The following rare events have been reported in clinical trials or in the literature in association with the use of intravenously administered nicardipine. Body as a Whole: fever, neck pain Cardiovascular: angina pectoris, atrioventricular block, ST segment depression, inverted T wave, deep-vein thrombophlebitis Digestive: dyspepsia Hemic and Lymphatic: thrombocytopenia Metabolic and Nutritional: hypophosphatemia, peripheral edema Nervous: confusion, hypertonia Respiratory: respiratory disorder Special Senses: conjunctivitis, ear disorder, tinnitus Urogenital: urinary frequency
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ADVERSE EXPERIENCES
Two hundred forty-four patients participated in two multicenter, double-blind, placebo-controlled trials of Cardene I.V. Adverse experiences were generally not serious and most were expected consequences of vasodilation. Adverse experiences occasionally required dosage adjustment. Therapy was discontinued in approximately 12% of patients, mainly due to hypotension, headache, and tachycardia.
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CARDENE I.V. (nicardipine hydrochloride) Sinus node dysfunction and myocardial infarction, which may be due to disease progression, have been seen in patients on chronic therapy with orally administered nicardipine. Cardene I.V. is NOT compatible with Sodium Bicarbonate (5%) Injection, USP or Lactated Ringers Injection, USP. THE DILUTED SOLUTION IS STABLE FOR 24 HOURS AT ROOM TEMPERATURE. Inspection: As with all parenteral drugs, Cardene I.V. should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Cardene I.V. is normally light yellow in color.
CARDENE I.V. (nicardipine hydrochloride) Impaired Cardiac, Hepatic, or Renal Function: Caution is advised when titrating Cardene I.V. in patients with congestive heart failure or impaired hepatic or renal function (see Precautions).
OVERDOSAGE
Several overdosages with orally administered nicardipine have been reported. One adult patient allegedly ingested 600 mg of nicardipine [standard (immediate release) capsules], and another patient, 2160 mg of the sustained release formulation of nicardipine. Symptoms included marked hypotension, bradycardia, palpitations, ushing, drowsiness, confusion and slurred speech. All symptoms resolved without sequelae. An overdosage occurred in a one-year-old child who ingested half of the powder in a 30 mg nicardipine standard capsule. The child remained asymptomatic.
Transfer to Oral Antihypertensive Agents

If treatment includes transfer to an oral antihypertensive agent other than Cardene capsules, therapy should generally be initiated upon discontinuation of Cardene I.V. If Cardene capsules are to be used, the rst dose of a TID regimen should be administered 1 hour prior to discontinuation of the infusion.
Based on results obtained in laboratory animals, lethal overdose may cause systemic hypotension, bradycardia (following initial tachycardia) and progressive atrioventricular conduction block. Reversible hepatic function abnormalities and sporadic focal hepatic necrosis were noted in some animal species receiving very large doses of nicardipine. For treatment of overdosage, standard measures including monitoring of cardiac and respiratory functions should be implemented. The patient should be positioned so as to avoid cerebral anoxia. Frequent blood pressure determinations are essential. Vasopressors are clinically indicated for patients exhibiting profound hypotension. Intravenous calcium gluconate may help reverse the effects of calcium entry blockade.
Dosage
As a Substitute for Oral Nicardipine Therapy The intravenous infusion rate required to produce an average plasma concentration equivalent to a given oral dose at steady state is shown in the following table:
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HOW SUPPLIED
Cardene I.V. (nicardipine hydrochloride) is available in packages of 10 ampuls of 10 mL as follows: 25 mg (2.5 mg/mL), NDC 67286-0812-3. Store at controlled room temperature 20 to 25C (68 to 77F), refer to USP Controlled Room Temperature. Freezing does not adversely affect the product, but exposure to elevated temperatures should be avoided. Protect from light. Store ampuls in carton until used.
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For Initiation of Therapy in a Drug Free Patient The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment.
Cardene I.V. is administered by slow continuous infusion at a CONCENTRATION OF 0.1 MG/ML. With constant infusion, blood pressure begins to fall within minutes. It reaches about 50% of its ultimate decrease in about 45 minutes and does not reach nal steady state for about 50 hours.
DOSAGE AND ADMINISTRATIION

Cardene I.V. (nicardipine hydrochloride) is intended for intravenous use. DOSAGE MUST BE INDIVIDUALIZED depending upon the severity of hypertension and the response of the patient during dosing. Blood pressure should be monitored both during and after the infusion; too rapid or excessive reduction in either systolic or diastolic blood pressure during parenteral treatment should be avoided.
When treating acute hypertensive episodes in patients with chronic hypertension, discontinuation of infusion is followed by a 50% offset of action in 30 7 minutes but plasma levels of drug and gradually decreasing anti-hypertensive effects exist for about 50 hours.
Titration: For gradual reduction in blood pressure, initiate therapy at 50 mL/hr (5.0 mg/hr). If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 25 mL/hr (2.5 mg/hr) every 15 minutes up to a maximum of 150 mL/hr (15.0 mg/hr), until desired blood pressure reduction is achieved.
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Oral Cardene Dose 20 mg q8h 30 mg q8h 40 mg q8h
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Equivalent l.V. Infusion Rate 0.5 mg/hr 1.2 mg/hr 2.2 mg/hr
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Preparation
WARNING: AMPULS MUST BE DILUTED BEFORE INFUSION Dilution: Cardene I.V. is administered by slow continuous infusion at a CONCENTRATION OF 0.1 MG/ML. Each ampul (25 mg) should be diluted with 240 mL of compatible intravenous uid (see below), resulting in 250 mL of solution at a concentration of 0.1 mg/mL. I.V. has been found to be compatible and stable in glass or polyvinyl chloride containers for 24 hours at controlled room temperature with: Dextrose (5%) Injection, USP Dextrose (5%) and Sodium Chloride (0.45%) Injection, USP Dextrose (5%) and Sodium Chloride (0.9%) Injection, USP Dextrose (5%) with 40 mEq Potassium, USP Sodium Chloride (0.45%) Injection, USP Sodium Chloride (0.9%) Injection, USP Cardene
For more rapid blood pressure reduction, initiate therapy at 50 mL/hr (5.0 mg/hr). If desired blood pressure reduction is not achieved at this dose, the infusion rate may be increased by 25 mL/hr (2.5 mg/hr) every 5 minutes up to a maximum of 150 mL/hr (15.0 mg/hr), until desired blood pressure reduction is achieved. Following achievement of the blood pressure goal, the infusion rate should be decreased to 30 mL/hr (3 mg/hr). Maintenance: The rate of infusion should be adjusted as needed to maintain desired response.
Cardene I.V. is a registered trademark of PDL BioPharma, Inc. U.S. Patent No.: 5,164,405 Copyright 2007 PDL BioPharma, Inc. Fremont, CA 94555 USA Manufactured by: Baxter Healthcare Corporation Deereld, IL 60015 USA Marketed by: PDL BioPharma, Inc. Fremont, CA 94555 USA Issued October 2007 120604 CAR0199
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Conditions Requiring Infusion Adjustment

Hypotension or Tachycardia: If there is concern of impending hypotension or tachycardia, the infusion should be discontinued. When blood pressure has stabilized, infusion of Cardene I.V. may be restarted at low doses such as 30 50 mL/hr (3.0 - 5.0 mg/hr) and adjusted to maintain desired blood pressure. Infusion Site Changes: Cardene I.V. should be continued as long as blood pressure control is needed. The infusion site should be changed every 12 hours if administered via peripheral vein.
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ll ri gh i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM n M tio c 08 du 2 0 ro ep t R gh d. ri e py erv Co es r ts

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NEUROLOGY
Harold P. Adams, Jr, MD Mark J. Alberts, MD Stephen A. Mayer, MD

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Stroke-PG07005

Guidelines on the Management of Hypertension for the Prevention and Treatment of

Stroke and Hypertensive Emergencies

Harold P. Adams, Jr, MD Mark J. Alberts, MD Stephen A. Mayer, MD

A ll ri gh i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM n M tio c 08 du 2 0 ro ep t R gh d. ri e py erv Co es r ts

This resource is provided to you as a professional courtesy by the sponsors of

anesthesiologynews.com PG07005 CAR0199

Please see prescribing information and important safety information inside.

Guidelines on the Management of Hypertension for the Prevention and Treatment of

Guidelines for the Management of Hypertension

Stroke and Hypertensive Emergencies

Management of Hypertension in the Setting of Elevated Intracranial Pressure ........................................................................... 36

List of Tables and Figures

20 08 M i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Table 10. 1994 AHA Guidelines on the Management of Subarachnoid Hemorrhage............................................................. 33 3

Section I. Guidelines for the Management of Hypertension

Table 1. End-Organ Effects of Chronic, Untreated Hypertension

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Treatment of Special Populations

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Section II. Primary and Secondary Prevention of Ischemic Stroke

Initial drug choices

Drug choices for patients without compelling indications

Figure 1. Recommended treatment approach for hypertension.

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Optimize doses or add additional drugs until goal BP achieved

Table 3. Overview of Oral Antihypertensive Agents

0.51.0 2.55 24 0.52 2080 2.510 510

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

BBs with intrinsic sympathomimetic activity

Acebutolol Penbutolol Pindolol

200800 1040 1040

Table 3. Overview of Oral Antihypertensive Agents

(continued) Usual Daily Frequency 2 2 1 2 12 1 1 1 1 1 1 1 1 12 1 12 1 1 12 1 1 1 2 12

Diltiazem extended-release Diltiazem extended-release Verapamil Verapamil immediate-release Verapamil long-acting

540 1040 1040 7.530 48 1080

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Table 3. Overview of Oral Antihypertensive Agents

* Dosing/scheduling based on individual drugs prescribing information.

ll ri gh Co ts py rv ed re se ri gh t 20 08 M du ro ep .R i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Adapted from reference 27

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Initial drug choices

Figure 2. Algorithm for the management of hypertensive emergencies.

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Begin oral AHT when BP reaches satisfactory level

Table 5. The Ideal Parenteral Hypertensive

Has minimal hypotension (overshoot)

Section III. Management of Hypertensive Emergencies

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

Table 6. Parenteral Agents for the Treatment of Hypertensive Emergencies

0.1-0.3 mcg/kg per min I.V. infusion

Most hypertensive emergencies; caution with glaucoma Eclampsia

10-20 min I.V. 20-30 min IM

1-4 h I.V. 4-6 h IM

i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct

5-100 mcg/min as I.V. infusion

0.25-10 mcg/kg/min as I.V. infusion

Most hypertensive emergencies; caution with high intracranial pressure or azotemia

Aortic dissection, perioperative

Table 6. Parenteral Agents for the Treatment of Hypertensive Emergencies

5-15 mg I.V. bolus

M i ib d. t e ro h no s p e i is n rw sio is he ot rm ss pe le ut un ho up wit ro G art ng n p i hi r is bl e o Pu ol h on w ah in cM on i ct