From the Guidelines
The target systolic blood pressure (SBP) after permissive hypertension post ischemic stroke should be below 180/105 mmHg for patients undergoing treatment with i.v. thrombolysis or mechanical thrombectomy, and below 140/90 mmHg for long-term secondary prevention in stable patients who remain hypertensive ≥3 days after an acute ischemic stroke.
Key Considerations
- The management of blood pressure in acute ischemic stroke depends on whether the patient is receiving i.v. thrombolysis or mechanical thrombectomy, with more proactive management of severe hypertension recommended in these cases 1.
- For patients not receiving i.v. thrombolysis or mechanical thrombectomy, there is no evidence for actively lowering BP unless it is extremely high (e.g. >220/120 mmHg), in which case an initial moderate relative reduction of 10%–15% over a period of hours may be considered 1.
- The blood pressure reduction should be gradual, typically aiming for a 15-25% reduction in the first 24 hours of this transition phase, to avoid precipitous drops that could compromise cerebral perfusion.
- First-line medications for this purpose include angiotensin-converting enzyme inhibitors (ACEIs) like ramipril (2.5-10 mg daily) or lisinopril (10-40 mg daily), or angiotensin receptor blockers (ARBs) such as losartan (50-100 mg daily), as well as calcium channel blockers like amlodipine (5-10 mg daily) 1.
Rationale
- The initial permissive hypertension approach (allowing SBP up to 220 mmHg) is based on the brain's impaired autoregulation after stroke, where higher pressures are needed to maintain adequate perfusion to the ischemic penumbra.
- However, prolonged hypertension increases the risk of hemorrhagic transformation, recurrent stroke, and other cardiovascular complications, necessitating this transition to more normal blood pressure targets after the acute phase.
- The most recent guidelines from the European Heart Journal (2024) provide the most up-to-date recommendations for blood pressure management in acute ischemic stroke, emphasizing the importance of individualized care and careful consideration of the patient's specific clinical context 1.
From the Research
Target Systolic Blood Pressure (SBP) after Permissive Hypertension post Ischemic Stroke
- The optimal target SBP after permissive hypertension post ischemic stroke is not clearly defined, but current guidelines suggest that a reasonable goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke 2.
- For patients with marked elevation in blood pressure, medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 2.
- For patients undergoing intravenous thrombolysis for acute ischemic stroke, it is recommended that the blood pressure be reduced and maintained below 185 mm Hg systolic for the first 24 hours 2.
Comparison of Antihypertensive Agents
- Labetalol and nicardipine are commonly used antihypertensives in the management of elevated blood pressure following an acute stroke, with comparable safety and efficacy outcomes 3, 4.
- Nicardipine may have a better therapeutic response compared to labetalol in achieving goal blood pressure, with a greater percentage of time spent within goal and less blood pressure variability 5.
- However, other studies have found no significant difference in time at goal blood pressure, blood pressure variability, and clinical outcomes between labetalol and nicardipine 3, 4.
Blood Pressure Management
- The current approach in acute ischemic stroke is permissive hypertension, in which antihypertensive treatment is warranted in patients with systolic blood pressure greater than 220 mm Hg, receiving thrombolytic therapy, or with concomitant medical issues 2, 6.
- The use of predictable and titratable medications that judiciously reduce (approximately 10% to 15%) the initial presenting mean arterial pressure is recommended in these situations 6.