From the Guidelines
For a stroke infarct patient, the blood pressure target should be below 180/105 mmHg if thrombolytic therapy is received, and permissive hypertension up to 220/120 mmHg may be allowed initially without thrombolysis, with gradual reduction after the first day, as recommended by the most recent guidelines 1.
Key Considerations
- In the acute phase (first 24-72 hours after stroke), management differs based on whether the patient received thrombolytic therapy.
- If thrombolysis (tPA) is received, blood pressure should be kept below 180/105 mmHg, as supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
- Without thrombolysis, permissive hypertension up to 220/120 mmHg may be allowed initially, with gradual reduction after the first day.
- For long-term management, the blood pressure target should generally be below 140/90 mmHg.
Medication Options
- First-line options include ACE inhibitors like lisinopril (10-40 mg daily) or ARBs like losartan (50-100 mg daily), often combined with a thiazide diuretic like hydrochlorothiazide (12.5-25 mg daily).
- Calcium channel blockers such as amlodipine (5-10 mg daily) are also effective.
Importance of Blood Pressure Control
- Blood pressure control is crucial as hypertension significantly increases the risk of recurrent stroke.
- The brain requires adequate perfusion pressure during recovery, which is why rapid, aggressive BP lowering is avoided immediately after an ischemic stroke.
Individualized Care
- The healthcare provider will adjust the specific target based on the patient's individual risk factors, comorbidities, and stroke characteristics, as emphasized in the guidelines 1.
From the Research
Blood Pressure Targets for Stroke Infarct Patients
The optimal blood pressure (BP) target for stroke infarct patients varies depending on the specific circumstances and the stage of stroke.
- For patients with acute ischemic stroke, the American Heart Association/American Stroke Association (AHA/ASA) recommends a BP target of < 180/105 mmHg for patients treated with intravenous tissue plasminogen activator 2, 3.
- For patients with acute intracerebral hemorrhage (ICH), the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg 2.
- For primary stroke prevention, the target BP for those with hypertension is < 140/90 mmHg, and self-measured BP is recommended to assist in BP control 3.
- Recent studies suggest a BP target of < 130/80 mmHg for both primary and recurrent stroke prevention 4, 3.
Considerations for Blood Pressure Management
When managing BP in stroke infarct patients, it is essential to consider the following factors:
- The risk of recurrent ischemic and hemorrhagic strokes 4.
- The stage of stroke, with different targets for acute, subacute, and chronic phases 3.
- The use of antihypertensive agents, such as labetalol, nicardipine, and hydralazine, and their potential effects on BP control and clinical outcomes 5, 6.
- The importance of individualizing BP targets based on the patient's specific needs and risk factors 4, 3.