Published in the December 2009 issue of Today’s Hospitalist
When O’Neil Pyke, MD, took over last year as director of a hospitalist program in Wilkes-Barre, Pa., discovered what, for him, was an unusual arrangement regarding the management of patients with intracerebral hemorrhage (ICH). The hospital’s neurosurgeons wanted to remain only consultants for these patients while medical doctors were the primary admitters, even for ICH patients who needed surgery.
Designating hospitalists and family physicians as attendings was the exact opposite of the protocol in place at the hospital Dr. Pyke had left. There, neurosurgeons took all ICH patients directly from the ED and managed them, even when patients needed no surgical intervention. That management included taking the lead (and frequently difficult) role in reducing patients’ blood pressure.
“I don’t necessarily have a huge problem with this model of care, but it’s different,” says Dr. Pyke, who directs the Wyoming Valley Hospitalist Group at Wilkes-Barre General Hospital. “It’s definitely making me rethink the way we approach the care of these patients.”
What Dr. Pyke calls a “paradigm shift” in how ICH patients are managed is taking place at community hospitals around the country. And even some academic centers with neuro-ICUs are now looking to hospitalists for cross coverage. That means that a growing number of hospitalists are having to confront what for many is a very strong fear factor “inculcated in medical school and residency “concerning patients with head bleeds and hemorrhagic strokes.
Many of those fears coalesce around the issue of what to do about these patients’ often soaring blood pressures. Even neurologists and stroke experts, after all, do not always agree on how patients should be optimally managed.
While a few trials have examined the safety, timing and dosing of antihypertensives, hospitalists have relatively scant evidence on when to start those medications and which targets are safe for most patients. That leaves many hospitalists outside their clinical comfort zone, even as neurosurgeons and neurologists expect hospitalists to expand their ever-growing scope of practice to include ICH patients.
A growing role for hospitalists
Dr. Pyke is a good example of how community-based hospitalists are being asked to care for ICH patients, often because there simply aren’t enough neurologists on staff. But even at academic centers, hospitalists are being asked to expand their role in caring for these patients.
At Swedish Medical Center in Seattle, for example, ICH patients typically go to the neuro-ICU to be managed by neurosurgical fellows and attendings. But according to hospitalist Sandeep Sachdeva, MD, the hospitalists and the neuro-ICU recently agreed that nocturnists will cover neurosurgical patients at night for medical issues. The fact that nocturnists will be the first hospitalists at Swedish to be involved in these cases, Dr. Sachdeva says, was one of the factors in his decision to start working (after 10 years in hospital medicine) as a nocturnist.
“Care management in terms of integrating medical and surgical aspects of ICH has always been a challenge,” he says.
Far from being afraid of managing ICH patients, Dr. Sachdeva sees the shift as an opportunity. After all, he points out, hospitalists already take care of many critically ill patients, and the majority of ICH patients don’t need surgery.
“I don’t see why hospitalists can’t manage these patients, as long as we have neurosurgery input if needed,” he says. Hospitalists’ unease about managing ICH reminds him of the discussions that took place 10 years ago, when hospitalists were first asked to care for patients with ischemic stroke.
“Hospitalists didn’t want to touch those patients,” Dr. Sachdeva says. “But my team now is so comfortable with ischemic stroke that we don’t find routine stroke care challenging enough.”
S. Andrew Josephson, MD, a neurohospitalist at the University of California, San Francisco (UCSF), says that hospitalists who work in ICUs might expect to increasingly take over ICH management.
“Neurosurgeons are stepping further and further back from this disease because there really is not a role for surgery in ICH,” points out Dr. Josephson, director of the neurohospitalist program and assistant professor of neurology at UCSF. The exceptions are cerebellar hemorrhages and those hemorrhages that are close to the surface. “Probably less than between 5% and 10% of ICH patients need surgical intervention,” he says.
Standardizing blood pressure thresholds
The reality, however, is that taking over management for ICH makes a lot of hospitalists nervous. Jan Blanchard, MD, a hospitalist and assistant professor of internal medicine at the University of New Mexico Health Sciences Center in Albuquerque, sums it up: “At least in my generation, and I’m 16 years out of residency, no matter where we trained, we weren’t taught a consistent attack plan on either post-bleed or post-stroke blood pressure control.”
Having an “attack plan” is critical, given the rates of hypertension in ICH patients and their risk of hematoma growth. A review in the July 8, 2008, issue of Circulation found that three-fourths of patients with ICH (and with ischemic stroke) experience acute hypertensive response, with systolic blood pressure (SBP) exceeding 140 and diastolic topping 90. That response, the study found, can last between two and 14 days.
To help her colleagues get more comfortable managing hypertension in these patients, Dr. Blanchard in 2007 tackled hypertension post-brain injury as part of her group’s ongoing best practice rounds. The issue was pressing, she notes, because the neurology service was referring blood pressure management to the hospitalists.
But an even bigger problem, she adds, was that the approaches taken by the physicians in her group to managing hypertension post-bleed or stroke were all over the map. “Cut-off targets to begin bringing blood pressure down ranged anywhere from 180 to 240,” Dr. Blanchard says.
After she researched treatment options, her group decided to use the 2007 American Heart Association/ American Stroke Association (AHA/ASA) guidelines for the management of spontaneous intracerebral hemorrhage and early ischemic stroke. Dr. Blanchard says she contacted one of the lead authors of those guidelines regarding the timeframe for bringing blood pressure to goal target. For ICH patients, those guidelines target a systolic blood pressure of more than 180 or a mean arterial pressure (MAP) above 130 for reduction. (For blood pressure targets for ischemic stroke patients, see “Permissive hypertension in ischemic stroke,” below.)
Because the fear is that rapid blood pressure reduction will lead to secondary ischemia, Dr. Blanchard says her group decided to follow the 10%-15% rule when reducing blood pressure, using IV antihypertensives to incrementally lower blood pressure no more than 10%- 15% a day.
Determining the cause of ICH
When choosing a blood pressure goal for ICH patients, Samir Belagaje, MD, clinical instructor of vascular neurology and neuro-recovery at the University of Cincinnati, also urges hospitalists to consider the cause of the ICH.
While ruptured aneurysms are more typically associated with subarachnoid hemorrhage, he points out, they can cause ICH. “If it’s a ruptured aneurysm or malformation of the brain vasculature,” he says, “it’s important to control the blood pressure because that limits the expansion of the bleeding, even at day 3 or 4.” His team shoots for a systolic blood pressure of 160 or less and a mean arterial pressure of less than 130, and uses nicardipine. If the aneurysm hasn’t been clipped or coiled, Dr. Belagaje’s team keeps systolic blood pressure even lower, at about 140.
Once the aneurysm is secure, Dr. Belagaje explains, the guidelines change. “Then we tend to allow the SBP to run high “160 to 200 “from day 3 on and possibly out to day 21,” he says. “In fact, we encourage it to prevent risk of vasospasm and ischemic damage.”
When the ICH is spontaneous, caused by hypertension or induced by warfarin, for example, gradual blood pressure reduction over three or four days has been the preferred approach, Dr. Belagaje observes, unless the systolic blood pressure is over 220. In that case, he starts lowering blood pressure at 24 to 48 hours, to a systolic blood pressure target of 160.
Regardless of the cause of ICH, Dr. Belagaje notes, in patients who start showing signs of neurological deterioration such as worsening weakness or slurred speech as the blood pressure comes down, hospitalists should start bringing it back up again.
“That’s the balancing act,” he acknowledges, “that gets sort of difficult.”
Taking a more aggressive stance
UCSF’s Dr. Josephson, however, takes a more aggressive approach than most ICH guidelines. He targets ICH patients whose systolic pressure is between 170 and 220 and tries to bring their mean arterial pressure below 110 “fairly quickly.”
“The guidelines say a MAP of 130, but I find that many of my patients have already met that goal when they show up,” Dr. Josephson says.
As to what constitutes “fairly quickly,” Dr. Josephson says he tries to get patients below that MAP threshold “within the first few hours.” The idea that lowering blood pressure could lead to secondary ischemia “a large part of hospitalists’ fears when it comes to lowering these patients’ blood pressure “”hasn’t really been borne out in clinical trials as being important,” says Dr. Josephson. “Most neurologists have thought that to be less of a problem.”
He adds that he expects his hypertension management practices to be reflected in new ICH guidelines that should be available within the next year. “I suspect,” says Dr. Josephson, “that new guidelines will endorse an even more aggressive stance on blood pressure.”
Until those guidelines are released, hospitalists cite two studies as offering some guidance.
One is the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) trial, which found that systolic blood pressure in ICH patients could be safely reduced to 140 using nicardipine. Experts point out, however, that the trial’s sample size was only 60.
And pilot data from the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage (INTERACT) trial, which was published in the May 2008 issue of The Lancet Neurology and drew on a significantly larger sample, found that reducing systolic pressure to a target of 140 significantly reduced hematoma expansion.
Physicians are waiting for hard data on blood pressure management from both ATACH 2 and INTERACT 2. For now, however, Swedish’s Dr. Sachdeva says the data already released “show us that you can substantially reduce SBP down without causing harm or worrying too much about ischemia, provided you go slowly.”
While the studies leave many questions unanswered, he adds, the data at least allow him to feel more comfortable in a situation where a patient has both an ICH and either chest pain or heart failure.
“You used to be stuck between a rock and a hard place where blood pressure treatment for both conditions was diametrically opposed,” says Dr. Sachdeva. Now, he adds, he’s more confident that he can reduce blood pressure further without causing penumbra ischemia. “Ultimately, it still boils down to tailoring blood pressure management to the patient, the underlying cause of the ICH and accompanying comorbidities.”
In Wilkes-Barre, Dr. Pyke says he and his team members stay abreast of the latest evidence in the medical care of ICH patients, periodically putting the topic of ICH management on the agenda of the group’s regular meetings.
“As directors, we need to be more aggressive in training hospitalists to be comfortable with this,” Dr. Pyke says. “We have to get to that point in the learning curve where we’re ready for the shift and we don’t fight it.”
Bonnie Darves is a freelance health care writer based in Seattle.
HOSPITALISTS MAY BE USED TO TREATING PATIENTS with ischemic stroke, but neurohospitalist S. Andrew Josephson, MD, says that many make one common mistake: They don’t allow blood pressure to be “permissively high in the acute setting.”
Dr. Josephson, who is director of the neurohospitalist program and assistant professor of neurology at the University of California, San Francisco, says that medicine doctors are so used to bringing blood pressure down to treat hypertension in the hospital that it’s difficult for them to let high blood pressures ride in patients with ischemic stroke who haven’t had tPA.
“But when you lower their blood pressure,” he notes, “you are lowering perfusion,” potentially creating more infarcted tissue.
Dr. Josephson doesn’t reduce his patients’ blood pressure initially unless it’s more than 220 over 120, consistent with current American Heart Association guidelines. (For ischemic stroke patients who’ve received tPA, their systolic blood pressure should be less than 185, he says.)
He admits that there’s not much in the way of evidence for how long permissive hypertension should last. He begins bringing down blood pressure within three to five days, before patients are discharged.
Permissive hypertension is so valuable in ischemic stroke, Dr. Josephson adds, that occasionally, for those rare ischemic stroke patients who show up with a low systolic blood pressure of, say, 100, “it’s not unreasonable to consider treating them with either fluids or vasopressors to raise their blood pressure for a short period of time, although this approach has little to no data to support it.”
Antihypertensives: Which drug to use?
WHEN CHOOSING AN ANTIHYPERTENSIVE to use in patients with intracerebral hemorrhage (ICH), Baney Nandlall, MD, a hospitalist with Central Florida Inpatient Medicine (CFIM), says his group’s drug of choice is IV nicardipine.
“It’s easy to dose, and it can be titrated 15 minutes after the bolus dose and increased by 5mg/kg,” says Dr. Nandlall, who’s part of the CFIM hospitalist service at Florida Hospital in Orlando, which has a comprehensive neuro-ICU and a corps of neuro-intensivists available for consults.
With nicardipine, he explains, he usually needs to give just a bolus dose and then two increases 15 minutes apart to reach target pressure. “Our neuros and nurses love it,” Dr. Nandlall says, “because it gives you a smooth reduction in blood pressure without any of the unwanted effects you get with nitroprusside.”
The latter drug, he notes, reduces blood pressure too rapidly, potentially increasing intracranial pressure and decreasing cerebral perfusion pressure. It’s also contraindicated in renal failure patients when needed for more than 24 hours. “The drug accumulates,” Dr. Nandlall says, “and has been associated with methemoglobinemia.”
Nicardipine is relatively contraindicated in patients with moderate to severe aortic stenosis because it reduces diastolic blood pressure, he adds. But according to Dr. Nandlall, it’s still easier to convert from nicardipine to oral calcium-channel blockers than from nitroprusside.
At the University of California, San Francisco, S. Andrew Josephson, MD, director of the neurohospitalist program and assistant professor of neurology, says his group relies on a combination of IV nicardipine plus labetalol.
“The risk with labetalol is bradycardia because it lowers the pulse rate, so we use a lot more nicardipine,” Dr. Josephson says. “But we find them both to be good agents.”
Experts point out that labetalol is much cheaper than nicardipine because it’s generic. And for some hospitalists, labetalol is the antihypertensive that they’re familiar with.
That’s the case for Jan Blanchard, MD, a hospitalist at University of New Mexico Health Sciences Center in Albuquerque. The use of IV nicardipine at her institution, Dr. Blanchard says, is restricted to the neuro-ICU and the medical ICU “two units that the hospitalists don’t cover.
Instead, the hospitalists, who staff a subacute care (SAC) unit as well as the floors, choose among IV labetalol, hydralizine or metropolol for SAC patients.
“The fact that intensivists cover our ICUs is a big factor in what drugs we rely on,” Dr. Blanchard says. “We see much more labetalol, and the more you use a drug, the more you keep using it.”