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Clinical Journal of the American Society of Nephrology : CJASN logoLink to Clinical Journal of the American Society of Nephrology : CJASN
. 2020 May 11;15(9):1352–1354. doi: 10.2215/CJN.00030120

How We Manage Hypertension in a Patient with a Recent Stroke

Tara I Chang 1,2,, Vivek Bhalla 1,2
PMCID: PMC7480561  PMID: 32393466

Introduction

Each year in the United States, nearly 800,000 people experience a stroke, which can cause detrimental effects on functional status, independence, and quality of life. Approximately 25% of these strokes are recurrent strokes with a case mortality rate of 41% (versus 22% for an initial stroke) (1). Thus, the importance of secondary stroke prevention efforts cannot be overemphasized. Nearly 70% of all patients who experience a stroke have a prior history of hypertension, and proper BP management is critical for secondary stroke prevention (2). However, there are relatively few trials focused on secondary (compared with primary) stroke prevention, which limits the opportunity to provide evidence-based recommendations. In the following article, we describe our approach to outpatient hypertension management in a patient with a recent stroke.

The Patient

Ms. A is a 58-year-old woman with a 10-year history of hypertension, previously well controlled on a single agent (losartan 50 mg once daily). She was in her usual state of health before suddenly developing facial numbness and right-sided weakness. She presents to her local hospital, where her BP is 189/89 mm Hg and imaging shows a 3.5-cm left basal ganglia hemorrhage. She is admitted to the intensive care unit where she is managed with intravenous antihypertensive medications, and her condition stabilizes. After 4 days, she is discharged home on losartan 100 mg daily, clonidine 0.1 mg every 8 hours, and hydralazine 75 mg every 8 hours. In addition, she is prescribed simvastatin 40 mg daily, gabapentin 100 mg daily, baclofen 10 mg twice daily, sertraline 50 mg daily, and lorazepam 0.5 mg thrice daily as needed for anxiety.

She is referred to our Hypertension Center by her local primary care provider for assistance with BP management. She is evaluated in our center 2 weeks after hospital discharge. Seated standardized office BP is 139/79 mm Hg. Heart rate is 70 beats per minute. Weight is 79 kg, and body mass index is 27 kg/m2. Her physical examination is notable for right-sided weakness in the upper and lower extremities. She denies using any over-the-counter medications, herbal medications, or dietary supplements. She does not use tobacco or illicit drugs.

Evaluation for Causes of Secondary Hypertension

This patient, who reportedly had previously well controlled hypertension on a single agent and recently presented with a hemorrhagic stroke in the setting of a hypertensive emergency, warrants an evaluation for secondary causes of hypertension. Specific screening tests will vary depending on the clinical scenario. This patient underwent testing for kidney parenchymal disease, renovascular disease, primary aldosteronism, obstructive sleep apnea, thyroid disorders, and pheochromocytoma, which were all negative.

BP Measurement and Targets

Current United States BP guidelines recommend targeting BP<130/80 mm Hg for most individuals, including those with a history of stroke (1). A trial that randomly assigned patients with a recent history of lacunar stroke to a systolic BP target of 130–149 versus <130 mm Hg showed a nonsignificant reduction in all strokes (hazard ratio, 0.81; 95% confidence interval, 0.64 to 1.03; P=0.08) and significantly lower rates of hemorrhagic stroke in the group with the lower BP target (3). Thus, for our patient, we targeted an office BP <130/80 mm Hg. Proper BP measurement technique is paramount. It is important to remember that there is no way to convert an improper office BP measurement that does not adhere to recommended protocols (4) into a proper, standardized one. In our Hypertension Center, we implemented a standardized BP measurement protocol into our clinic workflow, where patients undergo unattended automated oscillometric BP measurement with triplicate BP readings after a 5-minute rest period (5). This technique has been shown to correlate better with outcomes than routine clinic BP (6).

On further questioning, we found that she feels very anxious about the possibility of a recurrent stroke. She checks her BP at home using proper measurement techniques up to ten times per day. She has labile BP, with some measurements at goal but other systolic BP measurements as high as 180–200 mm Hg. She also often feels drowsy with frequent napping and therefore, sets her alarm clock to wake her up at 6 am and 10 pm specifically to remind her to take her clonidine and hydralazine.

We routinely ask patients to bring in their home BP monitors for patient-specific device calibration by a trained nurse. For this patient, we found it to be within an acceptable range when compared with the office BP. Current guidelines recommend use of out-of-office BP measured using an ambulatory BP monitor or home BP monitor for the diagnosis of hypertension. We also use out-of-office BP measurements in patients with an established diagnosis of hypertension to complement office BP measurements and provide a more comprehensive overview of the BP profile, particularly in patients who may be prone to BP lability, such as after a stroke (7). Moreover, home BP monitoring is associated with improved BP control rates and can be used to identify white coat and masked hypertension, which may have treatment implications.

Antihypertensive Regimen

Short-acting mediations, such as clonidine and hydralazine, are often used to manage BP in the hospital due to their quick onset of action. However, these agents are not considered first line for outpatient BP management (1). We often try to simplify the antihypertensive regimen with longer-acting medications that do not require multiple daily doses because it helps to improve medication adherence—a major problem in BP management (8). In this patient with a recent stroke, we had several additional reasons for streamlining her regimen by substituting longer-acting medications. First, short-acting agents (e.g., clonidine and hydralazine) have short onset, but also short offset of action, which likely contributed to the BP lability and exacerbated her anxiety; this in turn could lead to a further rise in her BP. Second, she was interrupting her sleep in order to take her medications at the proper time intervals, which negatively affected her quality of life. Third, clonidine may have been contributing to her drowsiness.

We continued her losartan 100 mg daily and added chlorthalidone 12.5 mg daily. Inhibitors of the renin-angiotensin system combined with thiazide diuretics are useful after stroke (9), although other long-acting agents from other classes such as calcium channel blockers can also be added as needed to achieve the target BP (1). We chose to continue the losartan to minimize the number of simultaneous changes to her medication regimen, but other agents in this class such as telmisartan, olmesartan, irbesartan, or azilsartan have a longer t1/2 and better BP lowering compared with losartan (10). We prefer chlorthalidone over other thiazide-type diuretics because its long t1/2 will help to reduce BP lability and better contribute to reaching target BP if medication adherence is an issue. We must weigh these issues against the additional education and need for monitoring of serum chemistries for hyponatremia, hypokalemia, and hyperuricemia/gout.

We gradually weaned her off the clonidine over the course of several days with close home BP monitoring. She noticed fewer BP spikes, improved energy, and decreased fatigue. We communicated on a weekly basis with the patient using the secure messaging system via the electronic health record. At the next clinic visit 6 weeks later, we increased the chlorthalidone to 25 mg daily and started to wean off the hydralazine. We also emphasized the importance of continued physical therapy, adherence to a low-sodium diet, and gradual weight loss. We continued to see the patient in clinic every 6–8 weeks for the next 8 months, with electronic communication as needed. We then gradually reduced the frequency of clinic visits after she was on a stable regimen with BP below target.

At her last clinic visit 4 years after her stroke, she still has some residual right-sided weakness but continues to have well controlled BP both in the office and at home on her two-drug, daily-dosing regimen. She lives independently and has not had any recurrent strokes. Her anxiety is also well controlled, requiring only the occasional use of lorazepam, and she checks her BP once or twice per day a few times per week. She continues to follow up with us in the Hypertension Center on an annual basis.

Summary

Patients with a recent stroke require very close monitoring of BP because effective BP control is the cornerstone of secondary stroke prevention. We focus on simplified regimens using long-acting BP medications that can improve the likelihood of adherence and reduce BP lability in all individuals, but particularly in the patient with a recent stroke. Frequent follow-up in person, by phone, or via electronic communications will also help to ensure that the target BP is achieved.

Disclosures

V. Bhalla reports personal fees and ownership stock from Pyrames, personal fees from Maxim Integrated, and personal fees from Relypsa, outside the submitted work. T.I. Chang reports personal fees from Novo Nordisk, Janssen, and Fresenius Medical Care Renal Therapies Group LLC; grants from Satellite Healthcare; personal fees from Tricida; personal fees from Gilead; and personal fees from AstraZeneca, outside the submitted work.

Footnotes

Published online ahead of print. Publication date available at www.cjasn.org.

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