From the Guidelines
Blood pressure goals after an acute stroke should be individualized based on the type of stroke and whether the patient is receiving thrombolytic therapy, with targets of <180/105 mmHg for those receiving thrombolytics and <220/120 mmHg for those not receiving thrombolytics, as recommended by the 2024 ESC guidelines 1.
Key Considerations
- For ischemic stroke patients not receiving thrombolytics, blood pressure should generally be maintained below 220/120 mmHg in the first 24-48 hours to avoid reducing cerebral perfusion to the ischemic penumbra 1.
- For those receiving thrombolytic therapy, blood pressure should be kept below 180/105 mmHg for at least 24 hours after treatment to minimize the risk of reperfusion injury and intracranial hemorrhage 1.
- In hemorrhagic stroke, more aggressive blood pressure control is recommended, with targets of systolic blood pressure below 140-160 mmHg, as suggested by the 2022 American Heart Association/American Stroke Association guideline 1.
Blood Pressure Management
- Common medications used for acute blood pressure management include labetalol, nicardipine, and clevidipine, which should be titrated carefully to achieve the desired blood pressure target 1.
- Aggressive blood pressure lowering should be avoided in the acute phase of ischemic stroke, while in hemorrhagic stroke, lowering blood pressure helps prevent hematoma expansion 1.
Long-term Blood Pressure Goals
- After the acute phase (typically after 48-72 hours), blood pressure goals shift toward standard secondary prevention targets of <130/80 mmHg for most patients, as recommended by the 2024 ESC guidelines 1.
From the Research
Blood Pressure Goals After Acute Stroke
The blood pressure goals after an acute stroke are as follows:
- For acute ischemic stroke, the optimal blood pressure management is still unclear, but guidelines recommend keeping blood pressure below 180/105 mmHg in patients treated with intravenous tissue plasminogen activator 2, 3.
- For acute intracerebral hemorrhages (ICH), the evidence supports immediate blood pressure lowering, targeting a systolic blood pressure of 140 mmHg 2, 4.
- The relationship between blood pressure and unfavorable clinical outcomes is probably positive in acute hemorrhagic stroke, but J- or U-shaped in acute ischemic stroke with an undetermined nadir blood pressure 4.
- Antihypertensive treatment is only recommended for severe hypertension, and further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke 4.
Blood Pressure Management Strategies
Different blood pressure management strategies are being explored, including:
- Mechanical thrombectomy, which has been shown to improve functional outcome in stroke patients over intravenous thrombolysis alone 5.
- Thrombolytic strategies, such as tenecteplase, which has shown improved rates of recanalization compared to tissue-type plasminogen activator (alteplase) 5.
- DNA- and von Willebrand factor-targeted thrombolytic strategies, which have shown promising results in experimental models of ischemic stroke 5.
Guidelines and Recommendations
Current guidelines recommend various blood pressure goals based on multiple factors, including thresholds specific to certain treatment interventions 3. However, there is limited evidence to support specific blood pressure targets, and variability in clinical practice is common 3.