From the Guidelines
Blood pressure guidelines for administering thrombolytics like Alteplase (tPA) require maintaining systolic blood pressure (SBP) below 185 mmHg and diastolic blood pressure (DBP) below 110 mmHg before initiating treatment, and then keeping SBP below 180 mmHg and DBP below 105 mmHg during and for 24 hours after administration. The management of blood pressure is crucial when administering thrombolytics to minimize the risk of complications, particularly intracranial hemorrhage 1. Key considerations include:
- Monitoring blood pressure frequently during treatment—every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and hourly thereafter until 24 hours post-treatment 1.
- Controlling blood pressure with antihypertensive medications if it exceeds the recommended thresholds, such as labetalol or nicardipine 1.
- Ensuring that blood pressure can be lowered safely to the recommended levels before initiating thrombolytic therapy 1. The most recent and highest quality study, the 2018 guidelines for the early management of patients with acute ischemic stroke, emphasizes the importance of careful blood pressure management during thrombolytic therapy to balance the benefits of reperfusion against the risks of bleeding complications 1.
From the Research
Blood Pressure Guidelines for Thrombolytics Administration
The administration of thrombolytics, such as Alteplase (tissue plasminogen activator, tPA), to patients with acute ischemic stroke is contraindicated in patients with a systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg 2.
Key Considerations
- Elevated blood pressure can lead to a delay in thrombolytic therapy, which is associated with increased morbidity 2.
- The optimal antihypertensive regimen for controlling blood pressure before alteplase therapy remains unclear 2.
- High systolic blood pressure after thrombolysis is associated with poor outcome, including symptomatic intracerebral hemorrhage, mortality, and reduced independence 3.
Blood Pressure Management
- Current guidelines suggest pharmacological intervention if systolic BP exceeds 180 mm Hg for ischemic stroke treated with intravenous thrombolysis 3.
- Withholding antihypertensive therapy up to 7 days in patients with a history of hypertension was associated with worse outcome, whereas initiation of antihypertensive therapy in newly recognized moderate hypertension was associated with a favorable outcome 3.
- The use of labetalol, nicardipine, or hydralazine to control blood pressure before alteplase administration has been studied, with labetalol being the most commonly used agent 2.
Thrombolytic Therapy Eligibility
- The majority of acute ischemic stroke patients do not meet accepted criteria for thrombolytic therapy, with most being ineligible due to delays in obtaining treatment 4.
- Strategies to reduce the time to treatment are needed to increase the eligibility of patients for thrombolytic therapy 4.
Additional Considerations
- Intra-arterial alteplase (IA tPA) is commonly used during mechanical thrombectomy for acute ischemic stroke, but specific indications and applications for its use remain undefined 5.
- The use of alteplase in peripheral arterial occlusive disease has been reviewed, with few prospective, randomized clinical trials and a lack of standardized protocols and endpoints 6.