Abstract 199: Antihypertensive Utilization in Hyperacute Intracerebral Hemorrhage Presenting to the Emergency Room

Abstract

Background: There is wide variability in approaches to treating hypertensive primary intracerebral hemorrhage (ICH). We sought to characterize the types of antihypertensive agents and the rapidity with which these agents are utilized in a cohort of severely hypertensive (SH) ICH patients presenting to the emergency department (ED) <2 hours from symptom onset. Methods: Cases presenting to the ED via ambulance in the first 2 hours after symptom onset with intracerebral hemorrhage on initial imaging were identified from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial of intravenous magnesium vs. placebo. All subjects provided consent in the field and were transported to their usual care hospital, and no guidance was provided on treatment. We defined SH ICH as having a SBP>180 at presentation. Results: Of 1700 stroke there were 369 (22%) cases with primary ICH and 220 cases (60%) of hypertensive ICH. They were evaluated in 53 separate EDs, with 175 cases (47%) at primary stroke centers (PSC). ICH cases had a mean [SD] age of 65 [13] years, 34% women, 79% White race, 34% Hispanic ethnicity, 80% pre-exisitng hypertension, 20% diabetes, 18% smokers; they were assessed in the field by paramedics a median [IQR] of 23 [15-40] and arrived in the ED 58 [46-77] minutes after onset. Overall 62% of ICH received antihypertensive (80% of ICH-SH, 39% ICH nonSH, p<0.001). Time in minutes from ED arrival to initiation of antihypertensive agent was 109 [SD160] in ICH-SH and 116 [SD198] in ICH-nonSH. Of the 214 who received antihypertensive therapy, 122 received short-acting/bolus therapy only, 70 continuous infusion only and 23 received both. The most commonly used short-acting/bolus therapy in the ED was labetalol in 111, hydralazine in 8, and enalapril in 5. The most commonly used continuous infusion was nicardipine (41), nitroprusside (35) and labetalol infusion (11). SBP was still elevated >180 in 37 (10%) At 4 hours after presentation. Time from ED to treatment was shorter at PSC EDs (73 vs. 144 minutes, p<0.001). Conclusion: There is wide variability in antihypertensive use among emergency departments in the studied geographic area. Despite high rates of treatment, there was a delay of 109 minutes in initiating therapy after ED arrival in ICH-SH.