Cerebrovascular risks with rapid blood pressure lowering in the absence of hypertensive emergency - 31/08/18

Doi : 10.1016/j.ajem.2018.08.052

Joseph B. Miller, MD, MS ^a,^b,^{^⁎} , Sean Calo, BS ^c, Brian Reed, BS ^d, Richard Thompson, BA ^e, Bashar Nahab, MD ^f, Evan Wu, MD ^g, Kaleem Chaudhry, BS ^h, Phillip Levy, MD, MPH ^i,^j
^a Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, United States of America
^b Department of Internal Medicine, Henry Ford Hospital and Wayne State University, Detroit, MI, United States of America
^c Central Michigan University School of Medicine, Mount Pleasant, MI, United States of America
^d Department of Emergency Medicine, Wayne State University, Detroit, MI, United States of America
^e Wayne State University School of Medicine, Detroit, MI, United States of America
^f Department of Radiology, Wayne State University, Detroit, MI, United States of America
^g Department of Emergency Medicine, University of California Davis, Davis, CA, United States of America
^h Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States of America
ⁱ Department of Emergency Medicine, Cardiovascular Research Institute, Wayne State University, Detroit, MI, United States of America
^j Department of Physiology, Wayne State University, Detroit, MI, United States of America

^⁎Corresponding author at: Department of Emergency Medicine, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, United States of America.Department of Emergency MedicineHenry Ford Hospital2799 W Grand BlvdDetroitMI48202United States of America

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Abstract

Study objective

In the Emergency Department (ED) setting, clinicians commonly treat severely elevated blood pressure (BP) despite the absence of evidence supporting this practice. We sought to determine if this rapid reduction of severely elevated BP in the ED has negative cerebrovascular effects.

Methods

This was a prospective quasi-experimental study occurring in an academic emergency department. The study was inclusive of patients with a systolic BP (SBP) > 180 mm Hg for whom the treating clinicians ordered intensive BP lowering with intravenous or short-acting oral agents. We excluded patients with clinical evidence of hypertensive emergency. We assessed cerebrovascular effects with measurements of middle cerebral artery flow velocities and any clinical neurological deterioration.

Results

There were 39 patients, predominantly African American (90%) and male (67%) and with a mean age of 50 years. The mean pre-treatment SBP was 210 ± 26 mm Hg. The mean change in SBP was −38 mm Hg (95% CI −49 to −27) mm Hg. The average change in cerebral mean flow velocity was −5 (95% CI −7 to −2) cm/s, representing a −9% (95% CI −14% to −4%) change. Two patients (5.1%, 95% CI 0.52–16.9%) had an adverse neurological event.

Conclusion

While this small cohort did not find an overall substantial change in cerebral blood flow, it demonstrated adverse cerebrovascular effects from rapid BP reduction in the emergency setting.

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