What is the management approach for blood pressure in acute stroke patients, including those with ischemic and hemorrhagic stroke?

From the Guidelines

Blood pressure management in acute stroke requires a balanced approach, with permissive hypertension generally recommended in the first 24-72 hours for ischemic stroke, allowing systolic blood pressures up to 220 mmHg and diastolic up to 120 mmHg without intervention unless there are other compelling indications for treatment, as supported by the most recent guidelines 1. The management approach for blood pressure in acute stroke patients differs between ischemic and hemorrhagic strokes.

• For ischemic stroke, permissive hypertension is recommended, allowing high blood pressures without intervention unless there are other indications for treatment.
• However, if the patient is receiving thrombolytic therapy with tPA, blood pressure should be maintained below 180/105 mmHg to reduce bleeding risk, typically using IV labetalol or nicardipine, as recommended by recent guidelines 1.
• For hemorrhagic stroke, more aggressive blood pressure control is warranted, with a target systolic pressure below 140-160 mmHg using continuous IV infusions of antihypertensives like nicardipine, clevidipine, or labetalol, as suggested by recent studies 1. The rationale for initial permissive hypertension in ischemic stroke is to maintain cerebral perfusion pressure in areas where autoregulation is impaired, while the stricter control in hemorrhagic stroke aims to prevent rebleeding and hematoma expansion.
• Blood pressure should be monitored frequently, ideally with automated cuff measurements every 15-30 minutes during the acute phase, and treatment adjusted accordingly, as recommended by guidelines 1. After the acute phase (generally after 72 hours), gradual blood pressure normalization should begin, targeting less than 140/90 mmHg for most patients, as suggested by recent guidelines 1. Key considerations in blood pressure management include:
• Maintaining cerebral perfusion pressure in ischemic stroke
• Preventing rebleeding and hematoma expansion in hemorrhagic stroke
• Monitoring blood pressure frequently and adjusting treatment accordingly
• Using appropriate antihypertensive agents, such as labetalol or nicardipine, to control blood pressure, as recommended by recent studies 1.

From the Research

Management Approach for Blood Pressure in Acute Stroke Patients

The management of blood pressure in acute stroke patients, including those with ischemic and hemorrhagic stroke, is a complex issue.

• The current approach is to allow permissive hypertension in the early course of acute ischemic stroke, as stated in 2.
• This means that antihypertensive treatment is only warranted in patients with systolic blood pressure greater than 220 mm Hg or diastolic blood pressure greater than 120 mm Hg, unless the patient is undergoing intravenous thrombolysis, in which case the blood pressure should be reduced and maintained below 185 mm Hg systolic for the first 24 hours 2.
• For patients with marked elevation in blood pressure, a reasonable goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke 2.
• The first-line drugs for lowering blood pressure in this setting are labetalol, nicardipine, and sodium nitroprusside 2.

Comparison of Antihypertensive Agents

Studies have compared the efficacy of different antihypertensive agents in acute stroke patients.

• One study found that nicardipine was superior to labetalol in achieving goal blood pressure and maintaining blood pressure control in patients with acute stroke 3.
• Another study found that continuous-infusion labetalol and nicardipine were comparable in terms of safety and efficacy in managing hypertension in stroke patients 4.
• These findings suggest that the choice of antihypertensive agent may depend on individual patient factors and clinical circumstances.

Individualized Blood Pressure Management

Recent studies have emphasized the importance of individualized blood pressure management in acute stroke patients.

• One review discussed the complexity of factors linking blood pressure changes to clinical outcomes in patients with acute ischemic stroke, and highlighted the need for personalized treatment strategies 5.
• Another study suggested that the optimal management of blood pressure in acute ischemic stroke may depend on the presence of comorbid conditions, such as arterial hypertension and organ dysfunction 6.
• Further research is needed to define optimal blood pressure goals and to develop personalized treatment protocols for acute stroke patients 2, 6, 5.