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Live at Annual Episode 1: Defining Blood Pressure Control in Acute Stroke with Dr Ali Seifi

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Description

Several measures of blood pressure (BP) control have been used including time to reach target BP, maintaining BP within target range, reducing BP fluctuation, achieving goals with monotherapy and avoiding multiple anti-hypertensive agents, achieving goals with minimum dose adjustments, avoiding discontinuation due to side effects, and preventing hypotension. There are multiple methods of quantifying these measures. The clinical relevance of various measures particularly relationship with acute kidney injury, and death or disability in patients with acute stroke or traumatic brain injury is not well understood. A better understanding of these measures is essential to identify the ideal therapeutic agent and for comparison of effectiveness between various antihypertensive agents. Dr Nick Morris is joined by Dr Ali Seifi, Director of Neuro ICU at University of Texas Health whose session at the Meeting focused on the need to review existing data to evaluate the relationship between various measures of BP control and acute kidney injury and death or disability in stroke patients.

Contributors

  • Ali Seifi, MD

  • Nicholas A. Morris, MD

    Assistant Professor and Fellowship Director
    Division of Neurocritical Care and Emergency Neurology
    Department of Neurology
    University of Maryland School of Medicine Medicine

  1. 00:00:22
    Hi, this is Nick Morris from the
  2. 00:00:24
    University of Maryland Medical Center at
  3. 00:00:25
    shock trauma hospital and I'm here at
  4. 00:00:28
    the NCS 2023 annual meeting who are live
  5. 00:00:31
    at annual podcasts. This is the first
  6. 00:00:33
    of hopefully many podcasts where we'll
  7. 00:00:36
    have session speakers, we'll do reviews
  8. 00:00:38
    from the day and try to pick out some
  9. 00:00:40
    real pearls that will help people at
  10. 00:00:41
    home who aren't attending live or even
  11. 00:00:44
    people at the meeting who didn't have
  12. 00:00:45
    the opportunity to get their questions
  13. 00:00:47
    answered So I'm here today live with Ali
  14. 00:00:50
    Safi who had one of the very first
  15. 00:00:51
    sessions of the morning on blood
  16. 00:00:54
    pressure after stroke. Ali, thanks so
  17. 00:00:57
    much for the wonderful session I was
  18. 00:00:58
    there. Maybe you could start by
  19. 00:01:00
    introducing yourself and giving us just
  20. 00:01:02
    a very brief synopsis of your session
  21. 00:01:05
    today. Thank you. I'm Ali Safi. I'm
  22. 00:01:08
    the professor of neuro-critical care at
  23. 00:01:10
    University of Texas in San Antonio So
  24. 00:01:15
    this morning actually I had to talk
  25. 00:01:16
    about the blood pressure control.
  26. 00:01:19
    stroke and neurocritical care, and
  27. 00:01:21
    particularly my section was emphasizing
  28. 00:01:24
    on blood pressure variability and
  29. 00:01:28
    fluctuation during the patient
  30. 00:01:29
    admissions at the hospital, and how
  31. 00:01:32
    this variable can impact the patient
  32. 00:01:34
    outcomes, such as the mortality and the
  33. 00:01:37
    functional outcome of the patient after
  34. 00:01:40
    these variabilities of the blood
  35. 00:01:41
    pressure, which is something for years,
  36. 00:01:44
    you know, the scientist is all working
  37. 00:01:45
    on absolute number of the systolic blood
  38. 00:01:48
    pressure or mean blood pressure, which
  39. 00:01:50
    one is more important, and or like what
  40. 00:01:53
    blood pressure number is the magic
  41. 00:01:55
    number that we should keep our patient
  42. 00:01:57
    at that number or below that number.
  43. 00:01:59
    However, recently, there is a shift of
  44. 00:02:02
    the transition toward focusing more on
  45. 00:02:05
    fluctuation of the blood pressure and
  46. 00:02:07
    the importance of this on the patient
  47. 00:02:09
    outcome, which I discussed this morning
  48. 00:02:11
    about this
  49. 00:02:14
    and you shared some really fascinating
  50. 00:02:16
    data showing that perhaps it's It's not
  51. 00:02:18
    the target so much that's important,
  52. 00:02:21
    but that fluctuation. And I think
  53. 00:02:23
    before your talk, we heard a little bit
  54. 00:02:27
    about the different orders of looking at
  55. 00:02:30
    blood pressure fluctuations. And one of
  56. 00:02:32
    the questions that might come up for
  57. 00:02:33
    some listeners is what timeframe are we
  58. 00:02:36
    talking about here in acute stroke? Is
  59. 00:02:39
    it within the first hours or does it go
  60. 00:02:42
    for days or even through the entire ICU
  61. 00:02:44
    stay? There is actually a very good
  62. 00:02:47
    question You know, of course, the
  63. 00:02:49
    blood pressure control starts from even
  64. 00:02:51
    the time before the stroke happened,
  65. 00:02:53
    before the patient come to the hospital.
  66. 00:02:55
    But the part that we can as a physician
  67. 00:02:58
    control more in intensive care units
  68. 00:03:01
    starts from the time the patient being
  69. 00:03:03
    picked up by the ambulances and when
  70. 00:03:05
    they call 911 from that moment that they
  71. 00:03:07
    pick up the patient. And then in the
  72. 00:03:09
    emergency room and followed up in the
  73. 00:03:11
    ICU to the end of admission. However,
  74. 00:03:15
    you know, the very first few days ICU
  75. 00:03:18
    admission is the important part that
  76. 00:03:21
    most of these studies, that they looked
  77. 00:03:24
    into the data, that they, it was
  78. 00:03:26
    during the first few days of admission,
  79. 00:03:28
    which was very relevant and associated
  80. 00:03:32
    with outcomes of the patients. Of
  81. 00:03:35
    course, blood pressure before and after
  82. 00:03:37
    admission also is important, but you
  83. 00:03:39
    know, there is no data about those
  84. 00:03:41
    before and after.
  85. 00:03:43
    And during your session, you shared a
  86. 00:03:46
    meta analysis that you completed
  87. 00:03:48
    comparing nichardepine and clovidepine.
  88. 00:03:50
    Do you mind sharing with listeners what
  89. 00:03:51
    your findings were from that meta
  90. 00:03:52
    analysis? Yeah. So, you know, I was
  91. 00:03:55
    always interested to see, okay, in the
  92. 00:03:57
    neurocritical care and stroke population,
  93. 00:04:00
    what will be like the good medication
  94. 00:04:03
    that we can have, least fluctuation,
  95. 00:04:07
    the best control, and fastest to be the
  96. 00:04:09
    target. Most of medication currently
  97. 00:04:12
    using for stroke are at a necardipane or
  98. 00:04:15
    clavidipane.
  99. 00:04:17
    which I started to do a meta-analysis.
  100. 00:04:20
    So in that meta-analysis I did for the
  101. 00:04:22
    patient on stroke, there are only about
  102. 00:04:24
    five studies that have been published
  103. 00:04:27
    that we could include because most of
  104. 00:04:29
    the others, they were kind of very
  105. 00:04:31
    biased. So from this five that we
  106. 00:04:34
    combined together, conclusion was
  107. 00:04:37
    pretty much these two medications are
  108. 00:04:40
    head to head, as far as the timing to
  109. 00:04:43
    the target, although clavitepin was
  110. 00:04:46
    about 23 minutes faster to reach the
  111. 00:04:48
    target. However, statistically there
  112. 00:04:50
    was no difference between like car pain
  113. 00:04:52
    and clavitepin. And as far as all the
  114. 00:04:55
    other parameters, they were very
  115. 00:04:56
    similar. The only one which
  116. 00:04:59
    statistically and significantly was
  117. 00:05:02
    better for clavitepin was the volume
  118. 00:05:05
    which was statistically lower than a car
  119. 00:05:08
    pain. So the bigger conclusion, I
  120. 00:05:12
    would say, can say it's gonna answer.
  121. 00:05:15
    When we reviewed as a meta-analysis,
  122. 00:05:17
    reviewing all the current literature,
  123. 00:05:20
    there is no good paper or good data that
  124. 00:05:23
    you can compare these medications or
  125. 00:05:26
    conclude something for the future. So,
  126. 00:05:30
    I would say my main conclusion will be
  127. 00:05:32
    we really need a prospective study to
  128. 00:05:36
    compare all of these current IV
  129. 00:05:38
    medications for ICUs to come up with at
  130. 00:05:41
    least some good information and data for
  131. 00:05:43
    other doctors and the patients.
  132. 00:05:47
    Great. And I think the million dollar
  133. 00:05:48
    question here is causation versus
  134. 00:05:50
    association whether these fluctuations
  135. 00:05:53
    are simply a marker of injury severity
  136. 00:05:57
    or whether this is these are modifiable
  137. 00:05:59
    factors that we can change to improve
  138. 00:06:01
    patient outcomes and so as you see it
  139. 00:06:04
    you mentioned a prospective study what
  140. 00:06:05
    are the real research priorities looking
  141. 00:06:08
    forward into blood pressure variability
  142. 00:06:10
    in stroke. Yeah. I think, you know,
  143. 00:06:13
    in the previous study that they checked
  144. 00:06:15
    the blood pressure variability when they
  145. 00:06:17
    adjusted for all the measurable
  146. 00:06:21
    variables such as demographics and also
  147. 00:06:24
    when they adjusted for the absolute
  148. 00:06:26
    systolic blood pressure number
  149. 00:06:28
    regardless of the fluctuation. The
  150. 00:06:30
    conclusion was that it looks like the
  151. 00:06:33
    main component that impacts the outcome
  152. 00:06:36
    is the fluctuation itself. So now the
  153. 00:06:39
    question is that is this the blood
  154. 00:06:41
    fluctuation directly itself that impacts
  155. 00:06:43
    the outcome or is the fluctuation
  156. 00:06:47
    causing something which that something
  157. 00:06:50
    is the one that impacting the patient
  158. 00:06:52
    outcome? So the perspective of the
  159. 00:06:55
    studies can actually help us with doing
  160. 00:06:58
    at the microscopic level to see what are
  161. 00:07:00
    the end organ damage that being caused
  162. 00:07:03
    by this fluctuation because those are
  163. 00:07:05
    probably the main reasons of the poorer
  164. 00:07:08
    outcome in higher fluctuations. but I
  165. 00:07:12
    think really there is not enough data
  166. 00:07:13
    and this is going to be helpful if they
  167. 00:07:16
    can do such a research.
  168. 00:07:19
    Wonderful. And then lastly to wrap up,
  169. 00:07:21
    you know, as I see it, there's
  170. 00:07:23
    multiple different things at play here.
  171. 00:07:25
    So there's patient factors, there's
  172. 00:07:27
    treatment factors and you've worked on
  173. 00:07:29
    this a little bit when you're
  174. 00:07:30
    meta-analysis, but there's also human
  175. 00:07:33
    and systems factors. So I would imagine,
  176. 00:07:36
    for instance, that nursing ratios might
  177. 00:07:40
    affect blood pressure variability or
  178. 00:07:43
    overall ICU acuity. Do we know anything
  179. 00:07:45
    about these behavioral human factors or
  180. 00:07:49
    systems factors and how they relate to
  181. 00:07:51
    blood pressure fluctuations after stroke?
  182. 00:07:54
    Actually, that's a very good question
  183. 00:07:56
    and I will add also to the human factors
  184. 00:08:01
    also, having protocols versus not
  185. 00:08:03
    having protocols because even
  186. 00:08:07
    in this meta-analysis we did, we found
  187. 00:08:09
    like the protocols between the different.
  188. 00:08:11
    hospital that they have been published
  189. 00:08:13
    is very, very different. And not only
  190. 00:08:16
    the protocol, and as you say, also the
  191. 00:08:19
    human, human factors, because you may
  192. 00:08:22
    see an institution that the nurses or
  193. 00:08:25
    even the ER physicians, they are more
  194. 00:08:27
    promptive to go control the blood
  195. 00:08:28
    pressure and in another institution,
  196. 00:08:31
    maybe, I don't know, because of the
  197. 00:08:33
    lack of enough human people to help or
  198. 00:08:37
    lack of the residents or physicians,
  199. 00:08:40
    the things are being slowed. So, and
  200. 00:08:43
    piggyback to this question, I would add
  201. 00:08:45
    also AI. So, with artificial
  202. 00:08:47
    intelligence, it will be very helpful
  203. 00:08:50
    and interesting to find all of this
  204. 00:08:53
    missing information in between to find,
  205. 00:08:55
    okay, what are the real lacking data
  206. 00:08:58
    reasons in this to find the reasoning
  207. 00:09:01
    behind this?
  208. 00:09:05
    Excellent. Well, thank you so much for
  209. 00:09:06
    your time and and congratulations on an
  210. 00:09:08
    excellent session. And we look. I look
  211. 00:09:10
    forward to hearing more from you and
  212. 00:09:11
    your team in research on blood pressure
  213. 00:09:13
    variability and fluctuations after
  214. 00:09:15
    stroke. Thank you. Thank you so much.