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Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review.
Neurocrit Care. 2022 10; 37(2):435-446.NC

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.

Links

Publisher Full Text (DOI)

Authors+Show Affiliations

Brown CS
Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. Brown.Caitlin1@mayo.edu.
Oliveira J E Silva L
Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
Mattson AE
Department of Pharmacy Services, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
Cabrera D
Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA.
Farrell K
Creighton University School of Medicine, Creighton University, Omaha, NE, USA.
Gerberi DJ
Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA.
Rabinstein AA
Division of Neurology, Mayo Clinic, Rochester, MN, USA.

MeSH

Antihypertensive AgentsBlood PressureEmergenciesHumansHypertensionLabetalolNicardipineNitroprusside

Pub Type(s)

Journal Article
Systematic Review
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

34993849

Citation

Brown, Caitlin S., et al. "Comparison of Intravenous Antihypertensives On Blood Pressure Control in Acute Neurovascular Emergencies: a Systematic Review." Neurocritical Care, vol. 37, no. 2, 2022, pp. 435-446.
Brown CS, Oliveira J E Silva L, Mattson AE, et al. Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. Neurocrit Care. 2022;37(2):435-446.
Brown, C. S., Oliveira J E Silva, L., Mattson, A. E., Cabrera, D., Farrell, K., Gerberi, D. J., & Rabinstein, A. A. (2022). Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. Neurocritical Care, 37(2), 435-446. https://doi.org/10.1007/s12028-021-01417-8
Brown CS, et al. Comparison of Intravenous Antihypertensives On Blood Pressure Control in Acute Neurovascular Emergencies: a Systematic Review. Neurocrit Care. 2022;37(2):435-446. PubMed PMID: 34993849.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparison of Intravenous Antihypertensives on Blood Pressure Control in Acute Neurovascular Emergencies: A Systematic Review. AU - Brown,Caitlin S, AU - Oliveira J E Silva,Lucas, AU - Mattson,Alicia E, AU - Cabrera,Daniel, AU - Farrell,Kyle, AU - Gerberi,Danielle J, AU - Rabinstein,Alejandro A, Y1 - 2022/01/06/ PY - 2021/09/22/received PY - 2021/11/30/accepted PY - 2022/1/8/pubmed PY - 2022/10/1/medline PY - 2022/1/7/entrez KW - Acute stroke KW - Antihypertensives KW - Blood pressure KW - Brain hemorrhage KW - Subarachnoid hemorrhages SP - 435 EP - 446 JF - Neurocritical care JO - Neurocrit Care VL - 37 IS - 2 N2 - 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. SN - 1556-0961 UR - https://www.unboundmedicine.com/medline/citation/34993849/Comparison_of_Intravenous_Antihypertensives_on_Blood_Pressure_Control_in_Acute_Neurovascular_Emergencies:_A_Systematic_Review_ DB - PRIME DP - Unbound Medicine ER -