g In patients who are candidates for t PA BP should be lowered to SBP less than

G in patients who are candidates for t pa bp should

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g.In patients who are candidatesfor t-PA, BP should be lowered to SBP less than 185 and DBP less than 110 prior to t-PA administration. After t-PA administration, SBP should be maintained less than 180 and DBP less than 105.4.When indicated, BP should be loweredby approximately 15% and closely watched for neurological deterioration related to decreased perfusion.5.The current 2013 Stroke Guidelines recommend the use of either labetalol, 10-20 mg IV push over 1-2 min, can repeat once; or nicardipine, intravenous drip titratable from 2.5-15 mg/hr for BP management.6.An alternative is esmolol (Brevibloc), 2.5 grams/250 ml NS or 2 grams/100 ml NS continuous infusion titrated to desired BP; maximum dose should not exceed 300 mcg/kg/min.C.Anticoagulation1.Intravenous heparin has historically been used as a treatment for acute stroke. However, it does not reduce the severity of a stroke that has occurred and is no longer routinely recommended.The decision to even consider the use of heparin in the acute management of stroke should be determined by a neurology expert.2.It may be used in patients with stroke in evolution and in hypercoagulable states, or in patients with very high-risk or recurrent emboli.3.Heparin may increase the risk of transformation from ischemic stroke to hemorrhagic stroke and, therefore, is notrecommended for massive stroke.
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4.No loading dose of heparin is recommended as the potential risk of hemorrhagic transformation is high. A maintenance infusion of 12 units/kg/hr (max 1000 units/hr) can be started. PTT should be 1.5-2.5 patient’s baseline value.5.Heparin followed by warfarin (5-10 mg/day PO) is indicated as secondary prevention in suspected cerebral embolism resulting from the following:a.Mural thrombusb.Mitral stenosisc.Atrial fibrillationd.Mechanical heart valves6.Several newer anticoagulants are nowon the market and targeted at stroke prevention for patients with atrial fibrillation or paroxysmal atrial fibrillation.a.Dabigatran (Pradaxa) is a direct thrombin inhibitor. Originally used to prevent thromboembolic events after orthopedic procedures, the randomized evaluation of long-term anticoagulation therapy (RE-LY) study demonstrated that dabigatran had benefit comparedwith warfarin for prevention of stroke in patients with atrial fibrillation.Food and Drug Administration approved in 2010 at 150 mg BID, or 75 mg BID in renally-impairedpatientsb.Apixaban (Eliquis) is a factor Xa inhibitor also recently approved for stroke prevention in patients with atrial fibrillation. Standard dose is 5 mg BID or 2.5 mg BID for patients greater than 80 years of age, body weight 60 kg or less, or Cr greater than 1.5 mg/dl.c.Rivaroxaban (Xarelto) is a factor Xa inhibitor approved for stroke prevention in patients withatrial fibrillation. Standard dose is20 mg daily with evening meal for patients with creatinine clearance greater than 50 ml/min, or 15 mg daily with evening meal for patients with creatinine clearance 15-50 ml/min. Avoid use when CrCl less than 15 mL/min.
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