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What is the blood pressure goal of a patient that is status post subarachnoid hemorrhage w/ ventricularostomy placement, for general management? Episode was 2 months ago.
Optional Information: Person's Gender: Female Person's Age: 60 Already Tried: Metorprolol 25mg twice daily. Blood pressures ranging in 140/90, but having days with BP control as a high as 180/54, and 150/108.
Hi, this is Dr Sathya. Thanks for your question and I am very glad to help you.
The target BP (Blood Pressure) is patients with any kind of bleeding in the brain including SAH (subarachnoid hemorrhage) is around 120/80. If the BP is above normal limits it increases the risk for rebleeding. This risk is very high for the first 1 or 2 weeks after the SAH, however the risk persists at least to some extent beyond that period too (for the next several months or so - until the ruptured blood vessel has healed fully). Of course even after that the BP needs to be maintained within the normal range (that is less than 120/80) but during the first several months after the SAH it is very vital to keep the BP within the normal range of 120/80, so that rerupture doesn't occur and also the ruptured aneurysm heals well.
The patient you mentioned here has BP ranging from 140/90 to 180 systolic and 108 diastolic which is definitely above the accepted range, especially for a patient who had SAH just about 2 months ago.
The dose of metoprolol can be optimized and hopefully that helps, if not switching over to other BP meds, or combination of metoprolol with another BP med is recommended, so that BP control is tight around 120/80 range, at least for the first several months after the SAH (which corresponds to about 6 months or so after the bleeding).
Please ask me if there are any further questions.
Thanks for the waiting!
All the best!
Best regards,
Dr Sathya.
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So is there a minimum blood pressure that must be maintained, or is this only during the acute crisis of SAH, say systolic around 160? Is there risk of dropping the blood pressure too much too fast? Would increasing dose of metoprolol 50mg twice daily be too rapid, or would it need to be increased more slowly say 25mg in AM and 50mg in PM? Thx
I have received the above additional information. I am typing the answer now and I will follow up at the earliest.
Best regardsDr Sathya.
(You may disregard the reply button unless you have any questions before my next post; and thanks for the waiting!)
Thanks for the waiting.
The BP maintenance for an ischemic stroke (due to arterial blockage) and bleeding conditions like SAH are different. In patients with ischemic stroke the BP needs to be maintained relatively high, especially in the early stages after the stroke to improve the perfusion to the brain. But with bleeding condition, unfortunately that approach is not prudent because if the BP is maintained high then it can aggravate the bleeding, induce rebleeding etc.
So in bleeding conditions like SAH etc the goal is to maintain the BP around the normal range of 120/80, as much as possible.
While during acute stages of bleeding a rapid normalization of BP is justified to stop the bleeding, however at this stage - that is about 2 months after the bleeding I concur with your point that such rapid decreases in BP should not be attempted. Rather it needs to be done gradually. Even at acute stages of bleeding ideally the BP needs to be reduced gradually, however due to high risk of continued bleeding or rebleeding generally BP is normalized rapidly in those circumstances.
Now bleeding being occurred around 2 months ago the BP is ideally normalized gradually so instead of increasing metoprolol to 50 twice daily immediately, rather it is ideally increased step by step first 25 in AM, 50 in PM, then 50 twice daily etc.
Experience: American Board Certified Neurologist, Internal Medicine