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Hao F, Yin S, Tang L, Zhang X, Zhang S. Nicardipine versus Labetalol for Hypertension during Acute Stroke: A Systematic Review and Meta-Analysis. Neurol India 2022; 70:1793-1799. [PMID: 36352567 DOI: 10.4103/0028-3886.359214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Current recommendations prescribe either nicardipine or labetalol as the first-line treatment for acute hypertension due to ease of use, availability, and low price. However, it is unclear if these drugs have different effectiveness and safety profiles. This systematic review and meta-analysis aimed to compare the efficacy and safety of labetalol and nicardipine in patients with acute stroke. MATERIALS AND METHODS MEDLINE via PubMed, Scopus, Embase, and Google Scholar databases were electronically searched for the eligible publications from inception until March 2022. All full-text journal papers in English which compared the efficacy of nicardipine with that of labetalol on lowering blood pressure (BP; or treating hypertension) in all subtypes of acute stroke were included. The Cochrane Collaboration tool was used to assess the risk of bias. Data were analyzed using specific statistical methods. RESULTS Following the abstract and full-text screening, this meta-analysis included five retrospective cohorts and one prospective pseudorandomized cohort. Nicardipine's effect on time at goal BP was significantly superior to that of labetalol in patients with acute stroke (0.275 standardized mean difference [SMD], 95% confidence interval [CI]: 0.112-0.438, P = 0.001). The incidence of adverse events was significantly higher in the nicardipine group than that in the labetalol group. The pooled odds ratio (OR) was 1.509 (95% CI: 1.077-2.113, I2 = 0.00%, P = 0.757). The quality of included studies was found to be low. CONCLUSION More prospective, comparative trials are needed to investigate the efficacy of BP management as well as clinical outcomes in acute stroke patients receiving continuous labetalol and nicardipine infusions.
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Affiliation(s)
- Fang Hao
- Department of Neurology, Liaocheng People's Hospital, Shandong Province, China
| | - Suna Yin
- Department of Operating Room, Liaocheng Veterans Hospital, Shandong Province, China
| | - Lina Tang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
| | - Xueguang Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
| | - Shubao Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
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2
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Lee K, Kim BJ, Han M, Kim J, Choi K, Shin D, Cha J, Kim D, Kim D, Ryu W, Park J, Kang K, Lee SJ, Kim JG, Oh M, Yu K, Lee B, Hong K, Cho Y, Choi JC, Park TH, Park S, Lee KB, Kwon J, Kim W, Sohn SI, Hong J, Lee J, Lee JS, Lee J, Gorelick PB, Bae H. Effect of Heart Rate on 1-Year Outcome for Patients With Acute Ischemic Stroke. J Am Heart Assoc 2022; 11:e025861. [PMID: 35535617 PMCID: PMC9238577 DOI: 10.1161/jaha.122.025861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Previous literature about the effect of heart rate on poststroke outcomes is limited. We attempted to elucidate (1) whether heart rate during the acute period of ischemic stroke predicts subsequent major clinical events, (2) which heart rate parameter is best for prediction, and (3) what is the estimated heart rate cutoff point for the primary outcome. Methods and Results Eight thousand thirty-one patients with acute ischemic stroke who were hospitalized within 48 hours of onset were analyzed retrospectively. Heart rates between the 4th and 7th day after onset were collected and heart rate parameters including mean, time-weighted average, maximum, and minimum heart rate were evaluated. The primary outcome was the composite of recurrent stroke, myocardial infarction, and mortality up to 1 year after stroke onset. All heart rate parameters were associated with the primary outcome (P's<0.001). Maximum heart rate had the highest predictive power. The estimated cutoff point for the primary outcome was 81 beats per minute for mean heart rate and 100 beats per minute for maximum heart rate. Patients with heart rates above these cutoff points had a higher risk of the primary outcome (adjusted hazard ratio, 1.80 [95% CI, 1.57-2.06] for maximum heart rate and 1.65 [95% CI, 1.45-1.89] for mean heart rate). The associations were replicated in a separate validation dataset (N=10 000). Conclusions These findings suggest that heart rate during the acute period of ischemic stroke is a predictor of major clinical events, and optimal heart rate control might be a target for preventing subsequent cardiovascular events.
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Affiliation(s)
- Keon‐Joo Lee
- Department of NeurologySeoul National University Bundang HospitalSeongnamKorea
- Department of NeurologyKorea University Guro HospitalSeoulKorea
| | - Beom Joon Kim
- Department of NeurologySeoul National University Bundang HospitalSeongnamKorea
| | - Moon‐Ku Han
- Department of NeurologySeoul National University Bundang HospitalSeongnamKorea
| | - Joon‐Tae Kim
- Department of NeurologyChonnam National University HospitalGwangjuKorea
| | - Kang‐Ho Choi
- Department of NeurologyChonnam National University HospitalGwangjuKorea
| | - Dong‐Ick Shin
- Department of NeurologyChungbuk National University & HospitalCheongjuKorea
| | - Jae‐Kwan Cha
- Department of NeurologyDong‐A University HospitalBusanKorea
| | - Dae‐Hyun Kim
- Department of NeurologyDong‐A University HospitalBusanKorea
| | - Dong‐Eog Kim
- Department of NeurologyDongguk University Ilsan HospitalGoyangKorea
| | - Wi‐Sun Ryu
- Department of NeurologyDongguk University Ilsan HospitalGoyangKorea
- Artificial Intelligence Research CenterJLK Inc.SeoulKorea
| | - Jong‐Moo Park
- Department of NeurologyUijeongbu Eulji Medical CenterEulji UniversitySeoulKorea
| | - Kyusik Kang
- Department of NeurologyNowon Eulji Medical CenterEulji University School of MedicineSeoulKorea
| | - Soo Joo Lee
- Department of NeurologyEulji University HospitalDaejeonKorea
| | - Jae Guk Kim
- Department of NeurologyEulji University HospitalDaejeonKorea
| | - Mi‐Sun Oh
- Department of NeurologyHallym University Sacred Heart HospitalAnyangKorea
| | - Kyung‐Ho Yu
- Department of NeurologyHallym University Sacred Heart HospitalAnyangKorea
| | - Byung‐Chul Lee
- Department of NeurologyHallym University Sacred Heart HospitalAnyangKorea
| | - Keun‐Sik Hong
- Department of NeurologyInje University Ilsan Paik HospitalGoyangKorea
| | - Yong‐Jin Cho
- Department of NeurologyInje University Ilsan Paik HospitalGoyangKorea
| | - Jay Chol Choi
- Department of NeurologyJeju National University HospitalJejuKorea
| | - Tai Hwan Park
- Department of NeurologySeoul Medical CenterSeoulKorea
| | | | - Kyung Bok Lee
- Department of NeurologySoonchunhyang University HospitalCollege of MedicineSeoulKorea
| | - Jee‐Hyun Kwon
- Department of NeurologyUlsan University HospitalUlsanKorea
| | - Wook‐Joo Kim
- Department of NeurologyUlsan University HospitalUlsanKorea
| | - Sung Il Sohn
- Department of NeurologyKeimyung University Dongsan Medical CenterDaeguKorea
| | - Jeong‐Ho Hong
- Department of NeurologyKeimyung University Dongsan Medical CenterDaeguKorea
| | - Jun Lee
- Department of NeurologyYeungnam University Medical CenterDaeguKorea
| | - Ji Sung Lee
- Clinical Research CenterAsan Medical CenterSeoulKorea
| | - Juneyoung Lee
- Department of BiostatisticsKorea UniversitySeoulKorea
| | - Philip B. Gorelick
- Davee Department of NeurologyNorthwestern University Feinberg School of MedicineChicagoIL
| | - Hee‐Joon Bae
- Department of NeurologySeoul National University Bundang HospitalSeongnamKorea
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Toyoda K, Yoshimura S, Fukuda-Doi M, Qureshi AI, Martin RH, Palesch YY, Ihara M, Suarez JI, Okada Y, Hsu CY, Itabashi R, Wang Y, Yamagami H, Steiner T, Sakai N, Yoon BW, Inoue M, Minematsu K, Yamamoto H, Koga M. Intensive blood pressure lowering with nicardipine and outcomes after intracerebral hemorrhage: An individual participant data systematic review. Int J Stroke 2021; 17:494-505. [PMID: 34542358 DOI: 10.1177/17474930211044635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Nicardipine has strong, rapidly acting antihypertensive activity. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine after onset of intracerebral hemorrhage on clinical outcomes were determined. METHODS A systematic review and individual participant data analysis of articles before 1 October 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving hyperacute intracerebral hemorrhage adults treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase ≥6 mL from baseline to 24-h computed tomography. SUMMARY OF REVIEW Three studies met the eligibility criteria. For 1265 patients enrolled (age 62.6 ± 13.0 years, 484 women), death or disability occurred in 38.2% and hematoma expansion occurred in 17.4%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.00-1.26 per 10 mmHg) and hematoma expansion (1.16, 1.02-1.32). Mean hourly systolic blood pressure from 1 h to any timepoint during the initial 24 h was positively associated with death or disability. Later achievement of systolic blood pressure to ≤140 mmHg increased the risk of death or disability (aOR 1.02, 95% CI 1.00-1.05 per hour). CONCLUSIONS Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h in hyperacute intracerebral hemorrhage was associated with lower risks of hematoma expansion and 90-day death or disability without increasing serious adverse events.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, USA
| | - Renee' Hebert Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, USA
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yasushi Okada
- Departments of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung
| | - Ryo Itabashi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Blood Pressure Control in Acute Stroke: Labetalol or Nicardipine? J Stroke Cerebrovasc Dis 2021; 30:105959. [PMID: 34217067 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To assess the safety and efficacy of continuous infusion (CIV)-labetalol compared to -nicardipine in controlling blood pressure (BP) in the acute stroke setting. MATERIALS Patients were eligible if they had a diagnosis of an acute stroke and were administered either CIV-labetalol or CIV-nicardipine. Study outcomes were assessed within the first 24 h of the antihypertensive infusion. RESULTS A total of 3,093 patients were included with 3,008 patients in the CIV-nicardipine group and 85 in the CIV-labetalol group. No significant difference was observed in percent time at goal BP between the nicardipine (82%) and labetalol (85%) groups (p = 0.351). There was also no difference in BP variability between nicardipine (37%) and labetalol (39%) groups (p = 0.433). Labetalol was found to have a shorter time to goal BP as compared to nicardipine (24 min vs. 40 min; p = 0.021). While CIV-nicardipine did have a higher incidence of tachycardia compared to labetalol (17% vs. 4%; p <0.001), the incidence of hypotension (13% vs. 15%; p = 0.620) and bradycardia (24% vs. 22%; p = 0.797) were similar. CONCLUSIONS These results indicate that CIV-labetalol and CIV-nicardipine are comparable in safety and efficacy in controlling BP for patients with acute stroke.
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Hawkes MA, Rabinstein AA. Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review. Neurology 2021; 97:316-329. [PMID: 34031208 DOI: 10.1212/wnl.0000000000012276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review the role of the acute hypertensive response in patients with intracerebral hemorrhage, current treatment options, and areas for further research. METHODS Review of the literature to assess 1) frequency of acute hypertensive response in intracerebral hemorrhage; 2) consequences of acute hypertensive response in clinical outcomes; 3) acute hypertensive response and secondary brain injury: hematoma expansion and perihematomal edema; 4) vascular autoregulation, safety data side effects of acute antihypertensive treatment; and 5) randomized clinical trials and meta-analyses. RESULTS An acute hypertensive response is frequent in patients with acute intracerebral hemorrhage and is associated with poor clinical outcomes. However, it is not clear whether high blood pressure is a cause of poor clinical outcome or solely represents a marker of severity. Although current guidelines recommend intensive blood pressure treatment (<140 mm Hg) in patients with intracerebral hemorrhage, 2 randomized clinical trials have failed to demonstrate a consistent clinical benefit from this approach, and new data suggest that intensive blood pressure treatment could be beneficial for some patients but detrimental for others. CONCLUSIONS Intracerebral hemorrhage is a heterogenous disease, thus, a one-fit-all approach for blood pressure treatment may be suboptimal. Further research should concentrate on finding subgroups of patients more likely to benefit from aggressive blood pressure lowering, considering intracerebral hemorrhage etiology, ultra-early randomization, and risk markers of hematoma expansion on brain imaging.
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Affiliation(s)
- Maximiliano A Hawkes
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Alejandro A Rabinstein
- From the Department of Neurological Sciences (M.A.H.), University of Nebraska Medical Center, Omaha; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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6
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Balla HZ, Cao Y, Ström JO. Effect of Beta-Blockers on Stroke Outcome: A Meta-Analysis. Clin Epidemiol 2021; 13:225-236. [PMID: 33762851 PMCID: PMC7982440 DOI: 10.2147/clep.s268105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/13/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Cardiovascular events and infections are common in the acute phase after stroke. It has been suggested that these complications may be associated with excessive sympathetic activation due to the stroke, and that beta-adrenergic antagonists (beta-blockers) therefore may be beneficial. Aim The aim of the current meta-analysis was to investigate the association between beta-blocker treatment in acute stroke and the three outcomes: mortality, functional outcome and post-stroke infections. Methods A literature search was performed using the keywords stroke, cerebrovascular disorders, adrenergic beta-antagonists, treatment outcome and mortality. Randomized clinical trials and observational studies were eligible for data extraction. Heterogeneity was investigated using I2 statistics. Random effect model was used when heterogeneity presented among studies; otherwise, a fixed-effect model was used. Publication bias was assessed using Egger’s test and by visually inspecting funnel plots. Results A total of 20 studies were eligible for at least one of the three outcomes. Two of the included studies were randomized controlled trials and 18 were observational studies. Quality assessments indicated that the risk of bias was moderate. The meta-analysis found no significant association between treatment with beta-blockers and any of the three outcomes. The studies analyzed for the outcomes mortality and infection were heterogeneous, while studies analyzed for functional outcome were homogeneous. The articles analyzed for mortality showed signs of publication bias. Conclusion The lack of significant effects in the current meta-analysis, comprising more than 100,000 patients, does not support the proposed beneficial effects of beta-blockers in the acute phase of stroke.
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Affiliation(s)
- Hajnal Zsuzsanna Balla
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jakob O Ström
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage. J Neurosurg Anesthesiol 2019; 31:199-211. [PMID: 29389729 DOI: 10.1097/ana.0000000000000493] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH. METHODS A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH. RESULTS We searched PubMed for articles using MeSH Terms "heart," "cardiac," hypertension," "hypotension," "blood pressure," "electro," "echocardio," "troponin," "beta natriuretic peptide," "adverse events," "arrhythmi," "donor," "ICH," "intracerebral hemorrhage." Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection. CONCLUSIONS Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.
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Sadeghi M, Saber H, Singh A, Hanni C, Parker D, Desai A, Mohamed W. Nicardipine Associated Risk of Short-Term Mortality in Critically Ill Patients with Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1168-1172. [PMID: 30683492 DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/01/2019] [Accepted: 01/06/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hypertensive emergency is commonly associated with acute ischemic stroke and can be a predictor of poor outcome in these patients. Nicardipine and labetalol are commonly administered for the treatment of acute hypertension following stroke. Yet, data are lacking on the safety of these agents in this setting. OBJECTIVE This study aimed to determine all-cause in-hospital mortality, medication-related hypotensive episodes, development of hospital acquired infections and hospital length of stay between nicardipine and labetalol use for the management of hypertension after acute ischemic stroke. METHODS This retrospective study used a prospective database of individuals admitted to the neurointensive care unit at a university-based hospital over 39 months. Patients with confirmed ischemic strokes were included in this analysis. Data were recorded for administration of nicardipine and labetalol following acute stroke. RESULTS A total of 244 patients with acute ischemic stroke were included in this analysis (mean age, 64.3 ± 15 years; 52.2% males). Nicardipine use after acute ischemic stroke was associated with an increased risk of 30-day mortality (odds ratio [OR]: 4.6, 95% confidence interval [CI] 1.3-15.7; P = .02). A single episode of hypotension in the first 72hours of admission was also significantly associated with mortality (OR 4.35 [95% CI 1.2-14.9]; P = .02). CONCLUSIONS Nicardipine was associated with an increased risk of short-term mortality after acute ischemic stroke. This may have been due to hypotension, tachycardia, or pulmonary edema which were not apparent in our study. Further studies are required to elucidate the cause of this association.
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Affiliation(s)
- Mahsa Sadeghi
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Hamidreza Saber
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Azara Singh
- Department of Pediatric Neurology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Claudia Hanni
- Department of Pharmacology, Wayne State Univeristy/Detroit Medical Center, Detroit, Michigan
| | - Dennis Parker
- Department of Pharmacology, Wayne State University, Detroit, Michigan
| | - Aaron Desai
- Department of Neurology, Wayne State University/Detroit Medical Center, Detroit, Michigan
| | - Wazim Mohamed
- Department of Neurology, Wayne State School of Medicine, Detroit, Michigan.
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Zierath D, Olmstead T, Stults A, Shen A, Kunze A, Becker KJ. Chemical Sympathectomy, but not Adrenergic Blockade, Improves Stroke Outcome. J Stroke Cerebrovasc Dis 2018; 27:3177-3186. [PMID: 30120036 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/06/2018] [Accepted: 07/04/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND A robust adrenergic response following stroke impairs lymphocyte function, which may prevent the development of autoimmune responses to brain antigens. We tested whether inhibition of the sympathetic response after stroke would increase the propensity for developing autoimmune responses to brain antigens. METHODS Male Lewis rats were treated with 6-hydroxydopamine (OHDA) prior to middle cerebral artery occlusion (MCAO), labetalol after MCAO, or appropriate controls. Behavior was assessed weekly and animals survived to 1 month at which time ELISPOT assays were done on lymphocytes from spleen and brain to determine the Th1 and Th17 responses to myelin basic protein (MBP), ovalbumin (OVA), and concanavalin A. A subset of animals was sacrificed 72 hours after MCAO for evaluation of infarct volume and lymphocyte responsiveness. Plasma C-reactive protein (CRP) was measured as a biomarker of systemic inflammation. RESULTS Despite similar initial stroke severity and infarct volumes, 6-OHDA-treated animals lost less weight and experienced less hyperthermia after stroke. 6-OHDA-treated animals also had decreased CRP in circulation early after stroke and experienced better neurological outcomes at 1 month. The Th1 and Th17 responses to MBP did not differ among treatment groups at 1 month, but the Th1 response to OVA in spleen was more robust in labetalol and less robust in 6-OHDA-treated animals. CONCLUSIONS Chemical sympathectomy with 6-OHDA, but not treatment with labetalol, decreased systemic markers of inflammation early after stroke and improved long-term outcome. An increase in Th1 and Th17 responses to MBP was not seen with inhibition of the sympathetic response.
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Affiliation(s)
- Dannielle Zierath
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Theresa Olmstead
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Astiana Stults
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Angela Shen
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Allison Kunze
- Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Kyra J Becker
- Department of Neurology, University of Washington School of Medicine, Seattle, WA.
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Maier IL, Becker JC, Leyhe JR, Schnieder M, Behme D, Psychogios MN, Liman J. Influence of beta-blocker therapy on the risk of infections and death in patients at high risk for stroke induced immunodepression. PLoS One 2018; 13:e0196174. [PMID: 29694433 PMCID: PMC5919008 DOI: 10.1371/journal.pone.0196174] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/06/2018] [Indexed: 11/22/2022] Open
Abstract
Background Stroke-induced immunodepression is a well characterized complication of acute ischemic stroke. In experimental studies beta-blocker therapy reversed stroke-induced immunodepression, reduced infection rates and mortality. Recent, heterogeneous studies in stroke patients could not provide evidence of a protective effect of beta-blocker therapy. Aim of this study is to investigate the potential preventive effect of beta-blockers in subgroups of patients at high risk for stroke-induced immunodepression. Methods Data from a prospectively derived registry of major stroke patients receiving endovascular therapy between 2011–2017 in a tertiary stroke center (University Medical Center Göttingen. Germany) was used. The effect of beta-blocker therapy on pneumonia, urinary tract infection, sepsis and mortality was assessed using multivariate logistic regression analysis. Results Three hundred six patients with a mean age of 72 ± 13 years and a median NIHSS of 16 (IQR 10.75–20) were included. 158 patients (51.6%) had pre-stroke- and continued beta-blocker therapy. Beta-blocker therapy did not reduce the incidence of pneumonia (OR 0.78, 95% CI 0.31–1.92, p = 0.584), urinary tract infections (OR 1.51, 0.88–2.60, p = 0.135), sepsis (OR 0.57, 0.18–1.80, p = 0.334) or mortality (OR 0.59, 0.16–2.17, p = 0.429). Strokes involving the insula and anterio-medial cortex increased the risk for pneumonia (OR 4.55, 2.41–8.56, p<0.001) and sepsis (OR 4.13, 1.81–9.43, p = 0.001), while right hemispheric strokes increased the risk for pneumonia (OR 1.60, 0.92–2.77, p = 0.096). There was a non-significantly increased risk for urinary tract infections in patients with beta-blocker therapy and insula/anterio-medial cortex strokes (OR 3.12, 95% CI 0.88–11.05, p = 0.077) with no effect of beta-blocker therapy on pneumonia, sepsis or mortality in both subgroups. Conclusions In major ischemic stroke patients, beta-blocker therapy did not lower post-stroke infection rates and was associated with urinary tract infections in a subgroup with insula/anterio-medial strokes.
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Affiliation(s)
- Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
- * E-mail:
| | - Johannes C. Becker
- Department of Neurology, St. Bernward Hospital Hildesheim, Hildesheim, Germany
| | | | - Marlena Schnieder
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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