Neurocritical Care

, Volume 30, Issue 1, pp 118–125 | Cite as

Nicardipine Reduces Blood Pressure Variability After Spontaneous Intracerebral Hemorrhage

  • Janelle O. PoyantEmail author
  • Philip J. Kuper
  • Kristin C. Mara
  • Ross A. Dierkhising
  • Alejandro A. Rabinstein
  • Eelco F. M. Wijdicks
  • Brianne M. Ritchie
Original Article



Blood pressure variability (BPV) is an independent predictor for early hematoma expansion, neurologic deterioration, and mortality. There are no studies on the effect of intravenous (IV) antihypertensive drugs on BPV. We sought to determine whether patients have more BPV with certain antihypertensive agents, in particular the effect of IV nicardipine.


We conducted a single-center, retrospective chart review of individuals diagnosed with spontaneous intracerebral hemorrhage (ICH) receiving labetalol, hydralazine, and/or nicardipine within 24 h of hospital admission to assess the primary endpoint of BPV, defined as the standard deviation of systolic BP, with labetalol and/or hydralazine compared to nicardipine ± labetalol and/or hydralazine. Repeated measures linear regression was performed to compare BPV over 24 h between regimens, and Cox proportional hazards regression was used to compare the time to goal SBP between regimens.


Of the 1330 patients screened, 272 were included in our analysis; those included had a mean age of 69 years with 87.9% of Caucasian race. A total of 164 patients received IV bolus antihypertensives alone (labetalol, hydralazine or both), and 108 patients received IV nicardipine with or without additional IV boluses (labetalol, hydralazine, or both). Those who had IV nicardipine had significantly less BPV (p = 0.04) and was more likely to attain an SBP goal < 140 mmHg (p < 0.01).


Our study suggests patients with ICH who do not receive a nicardipine-based antihypertensive regimen have more BPV, which has been associated with poor clinical outcomes. Prospective, randomized, controlled trials are needed to determine the impact of specific antihypertensive regimens on clinical outcomes.


Intracerebral hemorrhage Blood pressure variability Antihypertensive Nicardipine Labetalol Hydralazine Bolus Infusion 


Authors’ Contributions

JOP designed and directed this study and drafted the manuscript; BMR, AAR, EFMW and PJ participated in the conceptual framing of the study, data analysis, and revision of the manuscript; RAD and KCM completed the statically analysis of the manuscript.

Source of support

This study was funded by a research grant from Mayo Clinic Pharmacy Services Discretionary Fund.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Zhang Y, Reilly KH, Tong W, et al. Blood pressure and clinical outcome among patients with acute stroke in Inner Mongolia, China. J Hypertens. 2008;26:1446–52.CrossRefGoogle Scholar
  2. 2.
    Willmot M, Leonardi-Bee J, Bath PM. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension. 2004;43:18–24.CrossRefGoogle Scholar
  3. 3.
    Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–60.CrossRefGoogle Scholar
  4. 4.
    Parati G, Ochoa JE, Lombardi C, et al. Assessment and management of blood-pressure variability. Nat Rev Cardiol. 2013;10:143–55.CrossRefGoogle Scholar
  5. 5.
    Mancia G, Grassi G. Mechanisms and clinical implications of blood pressure variability. J Cardiovasc Pharmacol. 2000;35(7 Suppl 4):S15–9.CrossRefGoogle Scholar
  6. 6.
    Parati G, Ravogli A, Frattola A, et al. Blood pressure variability: clinical implications and effects of antihypertensive treatment. J Hypertens. 1994;12(5):S35–40.Google Scholar
  7. 7.
    Conway J, Boon N, Davies C, Jones JV, Sleight P. Neural and humoral mechanisms involved in blood pressure variability. J Hypertens. 1984;2(2):203–8.CrossRefGoogle Scholar
  8. 8.
    Dandapani BK, Suzuki S, Kelley RE, Reyes-Iglesias Y, Duncan RC. Relation between blood pressure and outcome in intracerebral hemorrhage. Stroke. 1995;26:21–4.CrossRefGoogle Scholar
  9. 9.
    Lattanzi S, Silvestrini M. Blood pressure in acute intra-cerebral hemorrhage. Ann Transl Med. 2016;4(16):320.CrossRefGoogle Scholar
  10. 10.
    Vemmos KN, Tsivgoulis G, Spengos K, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med. 2004;255:257–65.CrossRefGoogle Scholar
  11. 11.
    Buratti L, Cagnetti C, Balucani C, et al. Blood pressure variability and stroke outcome in patients with internal carotid artery occlusion. J Neurol Sci. 2014;339(1–2):164–8.CrossRefGoogle Scholar
  12. 12.
    Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. Blood pressure variability and clinical outcome in patients with acute intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2015;24:1493–9.CrossRefGoogle Scholar
  13. 13.
    Chung PW, Kim JT, Sanossian N, et al. Association between hyperacute stage blood pressure variability and outcome in patients with spontaneous intracerebral hemorrhage. Stroke. 2018;49(2):348–54.CrossRefGoogle Scholar
  14. 14.
    Liu-DeRyke X, Janisse J, Coplin WM, et al. A comparison of nicardipine and labetalol for acute hypertension management following stroke. Neurocrit Care. 2008;9:167–76.CrossRefGoogle Scholar
  15. 15.
    Liu-DeRyke X, Levy PD, Parker D Jr, Coplin W, Rhoney DH. A prospective evaluation of labetalol versus nicardipine for blood pressure management in patients with acute stroke. Neurocrit Care. 2013;19:41–7.CrossRefGoogle Scholar
  16. 16.
    Broderick JP, Adams HP, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1999;30(4):905–15.CrossRefGoogle Scholar
  17. 17.
    Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003;34(4):1056–83.CrossRefGoogle Scholar
  18. 18.
    Trandate (labetalol hydrochloride) injection [package insert]. San Diego, CA: Prometheus Laboratories Inc.; 2010.Google Scholar
  19. 19.
    Hydralazine hydrochloride injection [package insert]. Sirley, NY: American Regent, Inc.; 2013.Google Scholar
  20. 20.
    Cardene IV premixed injection (nicardipine) [package insert]. Deerfield, IL: Baxter Healthcare Corporation; 2010.Google Scholar
  21. 21.
    Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–7.CrossRefGoogle Scholar
  22. 22.
    Manning LS, Mistri AK, Potter J, Rothwell PM, Robinson TG. Short-term blood pressure variability in acute stroke: post hoc analysis of the controlling hypertension and hypotension immediately post stroke and continue or stop post-stroke antihypertensives collaborative study trials. Stroke. 2015;46:1518–24.CrossRefGoogle Scholar
  23. 23.
    Rodriguez-Luna D, Pineiro S, Rubiera M, et al. Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage. Eur J Neurol. 2013;20:1277–83.CrossRefGoogle Scholar
  24. 24.
    Tanaka E, Koga M, Kobayashi J, et al. Blood pressure variability on antihypertensive therapy in acute intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. Stroke. 2014;45:2275–9.CrossRefGoogle Scholar
  25. 25.
    Peacock WF, Varon J, Baumann BB, et al. CLUE: a randomized comparative effectiveness trial of IV nicardipine versus labetalol use in the emergency department. Crit Care. 2011;15:R157.CrossRefGoogle Scholar
  26. 26.
    Anderson CS, Huang Y, Wang JG, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. 2008;7:391–9.CrossRefGoogle Scholar
  27. 27.
    Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage (INTERACT 2). N Engl J Med. 2013;368:2355–65.CrossRefGoogle Scholar
  28. 28.
    Al Qureshi, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage (ATACH-II). N Engl J Med. 2016;375:1033–43.CrossRefGoogle Scholar
  29. 29.
    Rabinstein AA. Optimal blood pressure after intracerebral hemorrhage: still a moving target. Stroke. 2018;49(2):275–6.CrossRefGoogle Scholar
  30. 30.
    Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. How should we lower blood pressure after cerebral hemorrhage? A systematic review and meta-analysis. Cerebrovasc Dis. 2017;43(5–6):207–13.CrossRefGoogle Scholar
  31. 31.
    Finger JR, Kurczewski LM, Brophy GM. Clevidipine versus nicardipine for acute blood pressure reduction in a neuroscience intensive care population. Neurocrit Care. 2016;26:167–73.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  • Janelle O. Poyant
    • 1
    • 5
    Email author
  • Philip J. Kuper
    • 2
  • Kristin C. Mara
    • 3
  • Ross A. Dierkhising
    • 3
  • Alejandro A. Rabinstein
    • 4
  • Eelco F. M. Wijdicks
    • 4
  • Brianne M. Ritchie
    • 2
  1. 1.Department of Pharmacy ServicesTufts Medical CenterBostonUSA
  2. 2.Department of Pharmacy ServicesMayo ClinicRochesterUSA
  3. 3.Department of Biomedical StatisticsMayo ClinicRochesterUSA
  4. 4.Department of NeurologyMayo ClinicRochesterUSA
  5. 5.BostonUSA

Personalised recommendations