What are the optimal blood pressure targets following an acute cerebrovascular accident (CVA) or stroke?

From the Guidelines

Blood pressure goals after an acute stroke should be maintained below 220/120 mmHg if the patient is not receiving thrombolytic therapy or mechanical thrombectomy, and below 180/105 mmHg if thrombolytic therapy or mechanical thrombectomy is administered, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Considerations

• 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) 1.
• In patients undergoing treatment with i.v. thrombolysis, BP should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1.
• For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischaemic stroke, initiation or reintroduction of BP-lowering medication is recommended 1.

Blood Pressure Management

• The goal is to balance the need to maintain cerebral perfusion in damaged areas while preventing complications from hypertension.
• Overly aggressive blood pressure reduction early after stroke can reduce blood flow to the ischemic penumbra and worsen neurological outcomes.
• Common medications used include labetalol, nicardipine, and clevidipine, which can be titrated to achieve the desired blood pressure goals.

Comparison with Previous Guidelines

• The 2019 ESC council on hypertension position document on the management of hypertensive emergencies also recommends careful blood pressure management in acute stroke, but the 2024 guidelines provide more specific and updated recommendations 1.
• The 2024 guidelines prioritize a more conservative approach to acute BP management, emphasizing the importance of maintaining cerebral perfusion and avoiding overly aggressive blood pressure reduction.

From the Research

Blood Pressure Goals in Acute Stroke

• The optimal blood pressure goal in acute ischemic stroke is uncertain and may depend on the time window of treatment and the use of revascularization therapy 2, 3.
• In patients with acute ischemic stroke treated with intravenous tissue plasminogen activator, guidelines recommend a blood pressure goal of < 180/105 mmHg 2.
• For acute intracerebral hemorrhage, the evidence supports immediate blood pressure lowering targeting a systolic blood pressure of 140 mmHg 2, 3.
• The American Heart Association recommends antihypertensive therapy in acute ischemic stroke only if blood pressure is ≥ 220/120 mmHg with a goal of 15% to 25% reduction in the first 24 hours 4.
• Current guideline recommendations on blood pressure goals in acute stroke are clinically empirical and generally conservative, with antihypertensive treatment only recommended for severe hypertension 3.

Blood Pressure Management Strategies

• Aggressive blood pressure reduction in patients presenting with acute ischemic stroke is currently not recommended due to the lack of convincing evidence from clinical trials 2.
• The relationship between blood pressure and unfavorable clinical outcomes in acute ischemic stroke is likely J- or U-shaped, with an undetermined nadir blood pressure 3.
• Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, including the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke 3.