Abstract WP277: Aggressive Blood Pressure Management: A Perceived Contraindication to IV-tPA

Abstract

Background: Our recent poll of US Primary Stroke Centers demonstrated that 23% of practitioners perceived the need for blood pressure (BP) management by means of a continuous dihydropyridine calcium channel blocker infusion (i.e. nicardipine) as a contraindication to IV-tPA. While the NINDS study originally excluded patients who required "aggressive" BP management, the Activase® label is silent on this criterion. In view of this persistent belief, we sought to examine the safety of IV tPA administered with nicardipine. Methods: A retrospective cohort study was performed over a period of 36 months examining consecutive patients treated with IV-tPA at our comprehensive stroke center who received nicardipine vs. intermittent IV labetalol or those requiring no BP medications. Patient demographics, past medical history, and stroke severity were compared. Safety was assessed by (1) symptomatic intracerebral hemorrhage (sICH) within 36 hours, defined as parenchymal hemorrhage in combination with ≥ 4 points increase in NIHSS, and (2) the presence of any hemorrhagic transformation (HT) on repeat CT or MRI. Results: A total of 212 patients were treated with IV-tPA, median age 68 (range 24-99), median pre-tPA bolus NIHSS 8 (range 0-32) with no differences between nicardipine treated (n=32, 15%) vs. others (n=180). Patients treated with nicardipine were more frequently female (63%; p=0.0337). Past medical history was similar except for CHF (nicardipine 0, other 15%, p=0.0087) and previous stroke (nicardipine 59%, other 36%, p=0.0132). Despite these imbalances, nicardipine patients vs. others had similar rates of sICH (0 vs. 3.3%; p=NS), or any HT (3.1% vs. 9.5%; p=NS). No telephone-assisted tPA drip-n-ship patients (n=96) received nicardipine prior to or during tPA infusion due to non-formulary status at transferring hospitals; sICH rate in this group was 4% vs. 2% (p=NS) in non-transfers with or without nicardipine. Conclusions: IV thrombolysis in patients requiring continuous nicardipine infusion is safe compared to those requiring less intensive BP management. The need for continuous nicardipine infusion should not be construed as rationale for withholding IV tPA in acute ischemic stroke patients.