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Hypertension Requiring Continuous Infusion of Intravenous Antihypertensives

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Abstract

Background

Acute blood pressure (BP) management in neurologic patients is paramount. Different neurologic emergencies dictate various BP goals. There remains a lack of literature determining the optimal BP regimen regarding safety and efficacy. The objective of this study was to identify which intravenous antihypertensive is the most effective and safest for acute BP management in neurologic emergencies.

Methods

Ovid EBM (Evidence Based Medicine) Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection were searched from inception to August 2020. Randomized controlled trials or comparative observational studies that evaluated clevidipine, nicardipine, labetalol, esmolol, or nitroprusside for acute neurologic emergencies were included. Outcomes of interest included mortality, functional outcome, BP variability, time to goal BP, time within goal BP, incidence of hypotension, and need for rescue antihypertensives. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the degree of certainty in the evidence available.

Results

A total of 3878 titles and abstracts were screened, and 183 articles were selected for full-text review. Ten studies met the inclusion criteria; however, the significant heterogeneity and very low quality of studies precluded a meta-analysis. All studies included nicardipine. Five studies compared nicardipine with labetalol, three studies compared nicardipine with clevidipine, and two studies compared nicardipine with nitroprusside. Compared with labetalol, nicardipine appears to reach goal BP faster, have less BP variability, and need less rescue antihypertensives. Compared with clevidipine, nicardipine appears to reach goal BP goal slower. Lastly, nicardipine appears to be similar for BP-related outcomes when compared with nitroprusside; however, nitroprusside may be associated with increased mortality. The confidence in the evidence available for all the outcomes was deemed very low.

Conclusions

Because of the very low quality of evidence, an optimal BP agent for the treatment of patients with neurologic emergencies was unable to be determined. Future randomized controlled trials are needed to compare the most promising agents.

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Funding

This study was partially funded by the Mayo Midwest Pharmacy Research Committee.

Author information

Authors and Affiliations

  1. Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Caitlin S. Brown & Alicia E. Mattson

  2. Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA

    Lucas Oliveira J. e Silva & Daniel Cabrera

  3. Creighton University School of Medicine, Creighton University, Omaha, NE, USA

    Kyle Farrell

  4. Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA

    Danielle J. Gerberi

  5. Division of Neurology, Mayo Clinic, Rochester, MN, USA

    Alejandro A. Rabinstein

Contributions

C.S.B., L.O.J.S., A.E.M., D.C., and A.A.R. designed the study. C.S.B, A.E.M, K.F, L.O.J.S, and D.G. collected data, and C.S.B, A.E.M, L.O.J.S, D.C, and A.A.R analyzed and interpreted the data. C.S.B, L.O.J.S, A.E.M, and K.F drafted the article and all authors revised and approved of the final version. Previously presented in part at the 2021 American College of Clinical Pharmacy Annual Meeting.

Corresponding author

Correspondence to Caitlin S. Brown.

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Conflicts of interest

D.C.: Intellectual property royalties from Diagnostic Robotics, Israel. Intellectual property royalties from Osler Diagnostics, UK. A.A.R: Received royalties from Oxford, Elsevier, and Springer. Served on advisory board for Astra Zeneca and Novo Nordisk. Served on adverse event adjudication committee for Boston Scientific. The remaining authors have no conflicts to disclose.

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Given this is a systematic review, no institutional review board approval was required.

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Brown, C.S., Oliveira J. e Silva, L., Mattson, A.E. et al. Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. Neurocrit Care 37, 435–446 (2022). https://doi.org/10.1007/s12028-021-01417-8

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  • DOI : https://doi.org/10.1007/s12028-021-01417-8

Keywords

  • Antihypertensives
  • Blood pressure
  • Acute stroke
  • Subarachnoid hemorrhages
  • Brain hemorrhage

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