Inr normal range with acute stroke1/17/2024 ![]() ![]() Uncontrolled blood pressure is an uncommon reason for ineligibility of IV alteplase for AIS. While there is no established definition of “non-aggressive” blood pressure reduction, a common approach is to use a maximum of two to three attempts with parenteral medications, with options including labetalol, enalaprilat or nicardipine. Thrombolytic therapy is not given to patients who have a systolic blood pressure above 185 mmHg or a diastolic blood pressure above 110 mmHg despite non-aggressive blood pressure-lowering attempts. Excessively high blood pressures are associated with intracerebral hemorrhage after thrombolytic administration. Note: Other oral antihypertensive medications (e.g., diuretics, captopril,clonidine, metoprolol, and hydralazine) may be utilized for maintenance therapy if the patient has passed a dysphagia screeningīP blood pressure, IV intravenous, rtPA recombinant tissue plasminogen ActivatorĪmong patients who are candidates for treatment with thrombolytic agents, careful management of blood pressure is critical before and during the administration of alteplase (recombinant tissue plasminogen activator ), and for the ensuing 24 hours. If BP is maintained >185/110 mmHg, do not give alteplase Over 1–2 min, may repeat at double doses or nitropaste 1–2 in (2.5–5 cm) or nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5- to 15-min intervals, maximum dose 15 mg/h when desired BP attained, reduce to 3 mg/h. Sodium nitroprusside 0.25 µg/kg/ min IV with continuous BP monitoring if nicardipine is infective (target 10–15 % reduction) May repeat or double every 10 min to a maximum of 300 mg or an IV infusion Nicardipine 5 mg/h IV infusion, titrate to desired effect, to a maximum of 15 mg/h (target 10–15 % reduction) Sublingual use of a calcium channel antagonist, such as nifedipine, should be avoided because of rapid absorption and a secondary precipitous decline in blood pressure. Patients also can be treated with oral agents, such as labetalol or lisinopril, for more sustained blood pressure lowering if dysphagia is not a concern. In some cases, an intravenous (IV) infusion of nicardipine or labetalol may be necessary for adequate blood pressure control and this allows for careful titration. Parenteral agents such as labetalol that are easily titrated and that have minimal vasodilator effects on cerebral blood vessels are preferred. When treatment is indicated, lowering the blood pressure should be done cautiously to minimize the chance of relative hypotension. The consensus is that antihypertensive agents should be withheld unless the diastolic blood pressure is above 120 mmHg or unless the systolic blood pressure is above 220 mmHg ( Table 1). Although severe hypertension is a contraindication for thrombolytic therapy, there are no data to define the levels of arterial hypertension that mandate emergent management. In the setting of AIS, many patients will have elevated blood pressure for the first 24–48 hours. Ongoing clinical trials may lead to further medical breakthroughs to limit the damage inflicted by this devastating disease. The majority of AIS patients do not receive thrombolytic therapy due to late arrival to emergency departments and currently there is a paucity of acute interventions for them. Urgent antiplatelet use for AIS has limited benefits and should only promptly be initiated if alteplase was not administered, or after 24 hours if alteplase was administered. Urgent anticoagulation for AIS has generally not shown benefits that exceed the hemorrhage risks in the acute setting. Other acute supportive interventions for AIS include maintaining normoglycemia, euthermia and treating severe hypertension. Recent trials have shown this time window may be extended from 3 to 4.5 hours in select patients. ![]() Alteplase must be administered within a short time window to appropriate patients to optimize its therapeutic efficacy. Plasmin targets the blood clot with limited systemic thrombolytic effects. Intravenous alteplase promotes thrombolysis by hydrolyzing plasminogen to form the proteolytic enzyme plasmin. Drug treatment of AIS involves intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator ). AIS most commonly occurs when a blood vessel is obstructed leading to irreversible brain injury and subsequent focal neurologic deficits. Acute ischemic stroke (AIS) is the fourth leading cause of death and the leading cause of adult disability in the USA. ![]()
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