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Three Part Question

In [stroke patients with a high blood pressure] is [labetalol a better drug then other anti hypertensives] in [controlling the blood pressure].

Clinical Scenario

A 72-year-old gentleman presents to ED with symptoms of a Stroke arisen within the last hour. His wife rushed him to ED. A middle cerebral artery infarction is confirmed on diffusion weighted MR scan. The Stroke Team Consultant is called to consider thrombolysis. On noting that the patient has a high blood pressure, he wants the patient started on a Labetalol infusion prior to administration of thrombolytic agent. Amongst other things the question of evidence on the best anti hypertensive drug to be used in such a situation arises

Search Strategy

(stroke OR brain OR infarction) AND (control$) AND (blood pressure OR hypertens$) AND (labetalol OR antihypertens$).
[Limit to: Humans and English Language]
Medline Search using institutional Ovid Access, no date limits set.

(stroke OR brain OR infarction) AND (control$) AND (blood pressure OR hypertens$) AND (labetalol OR antihypertens$).
[Limit to: Humans and English Language]

Google Search: Stroke, Hypertension, High Blood pressure, Labetalol.

Search Outcome

Initial search through Medline on the above search criteria turned up 951 hits. Since it did not reveal any significant conclusive evidence, I looked at the Cochrane reviews and through references provided on that, the Stroke guidelines of the American Heart Association. The AHA Stroke Guidelines looked at optimal blood pressure readings prior to considering thrombolysis and also the adverse effects of both hyper and hypotension on the prognosis of such patients. Even though there is a suggested protocol in the guidelines on treating blood pressure, the evidence supporting the use of Labetalol per se is not conclusive

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

Conclusive data is still not available on the 3-part question. Further studies are needed to gain statistically significant evidence. My question aimed at answering what would help with forming a local ED protocol prior to considering thrombolysis in brain infarction, in some ways goes unanswered but does get a bearing

Clinical Bottom Line

local departmental policies should be developed in liaison with the Stroke Team. It is advised that local guidelines are adhered to in the interim.

References

1. Potter Controlling hypertension and hypotension immediately post stroke (CHHIPS)--a randomised controlled trial.