What is the recommended systolic blood pressure (SBP) management in patients post-thrombolytics?

From the Guidelines

The recommended systolic blood pressure (SBP) management in patients post-thrombolytics is to maintain SBP below 180 mmHg. After thrombolytic therapy, blood pressure should be monitored frequently, typically every 15 minutes for the first 2 hours, then every 30 minutes for the next 6 hours, and hourly thereafter for the first 24 hours. If SBP exceeds 180 mmHg, antihypertensive medications should be administered promptly. First-line agents include intravenous labetalol (10-20 mg over 1-2 minutes, may repeat every 10 minutes up to 300 mg) or nicardipine infusion (starting at 5 mg/hour, titrating by 2.5 mg/hour every 5-15 minutes, maximum 15 mg/hour) 1. For refractory hypertension, sodium nitroprusside may be considered at 0.5-10 mcg/kg/minute.

Key Considerations

• The goal is to avoid overtreating patients with stroke until definitive data are available 1.
• The brain's autoregulatory mechanisms are often impaired in the setting of acute stroke, making the tissue particularly vulnerable to pressure-related bleeding complications 1.
• Elevated blood pressure may increase cerebral perfusion in the ischemic zone, where autoregulation is lost and perfusion is pressure dependent 1.
• Rapid lowering of blood pressure may induce worsening of neurological symptoms by inducing lowered perfusion pressures to the area of ischemia 1.

Monitoring and Treatment

• Blood pressure should be monitored and assessed continually for causative factors of rises 1.
• Elevated blood pressure may be due to a physiological response to hypoxia, increasing ICP, hemorrhagic transformation, full bladder, pain, nausea, a loud environment, or preexisting hypertension 1.
• The AHA guidelines recommend that blood pressure should not be treated in the hyperacute period unless one of the following exists: Systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg after repeated measurements; cardiac ischemia, heart failure, or aortic dissection is present; thrombolytic therapy is planned; or ICH is identified 1.

Management of Blood Pressure During and After Treatment

• Blood pressure management during and after treatment with rtPA or other acute recanalization therapy includes monitoring every 15 minutes during treatment and then for another 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours 1.
• If blood pressure does not decrease and cannot be maintained below the target levels of 185/110 mm Hg, rtPA should not be administered 1.

From the Research

Post-Thrombolytic Systolic Blood Pressure Management

• The recommended systolic blood pressure (SBP) management in patients post-thrombolytics is a topic of ongoing research and debate 2, 3, 4.
• Most guidelines for intravenous thrombolysis (IVT) in acute ischemic stroke patients advise keeping systolic blood pressure (BP) below 180/105 mmHg prior to the bolus injection 2.
• However, the optimal management of BP after thrombolysis is less clear, with some studies suggesting that lower attained SBP and smaller SBP variability are associated with favorable outcomes 3.
• A systematic review and meta-analysis found that higher prethrombolysis systolic BP was significantly associated with poorer 90-day functional outcome and increased incidence of symptomatic intracranial hemorrhage (sICH) 4.
• Another study found that patients with post-thrombolytic sICH had significantly higher systolic BP at several time-points compared with patients without sICH 2.

Blood Pressure Targets

• The ENCHANTED study found that attaining early and consistent low levels in SBP <140 mmHg, even as low as 110 to 120 mmHg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients 3.
• Current guidelines recommend a BP target of 185/110 mmHg before IV-tPA bolus and maintaining it at less than 180/105 mmHg for the first 24 hours 4.
• However, some studies suggest that more aggressive lowering of BP below the current recommendations prior to thrombolysis could be beneficial 4.

Antihypertensive Agents

• The choice of antihypertensive agent for blood pressure control in patients with acute ischemic stroke is not well established, with labetalol and nicardipine being commonly used options 5, 6.
• A retrospective cohort study found that continuous-infusion labetalol and nicardipine were comparable in terms of safety and efficacy outcomes, including time at goal BP and BP variability 6.