What are the guidelines for controlling hypertension after an acute stroke?

From the Guidelines

Blood pressure management after an acute stroke should prioritize permissive hypertension, avoiding treatment unless blood pressure exceeds 220/120 mmHg, except in cases where thrombolysis is administered, in which case blood pressure should be maintained below 180/105 mmHg. This approach is based on the most recent guidelines, including the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The guidelines emphasize that the beneficial effects of blood pressure reduction in acute ischemic stroke remain unclear, and a conservative approach is recommended to avoid impairing cerebral autoregulation and maintaining cerebral perfusion.

Key considerations in blood pressure management after acute stroke include:

• Avoiding rapid blood pressure reduction, which may worsen cerebral perfusion and extend the ischemic area
• Using intravenous antihypertensive agents, such as labetalol or nicardipine, to control blood pressure in cases where thrombolysis is administered
• Gradually introducing oral antihypertensives after the acute phase (>72 hours) to achieve target blood pressures of <130/80 mmHg for secondary prevention
• Selecting medications based on individual patient characteristics and comorbidities, such as ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics.

It is essential to note that the optimal approach to blood pressure management after acute stroke may vary depending on individual patient factors, such as stroke type, severity, and comorbidities. Therefore, a cautious and personalized approach is recommended, taking into account the latest guidelines and evidence-based practices 1.

From the Research

Guidelines for Controlling Hypertension after Acute Stroke

• The management of hypertension after an acute stroke is crucial to prevent further brain damage and improve patient outcomes 2, 3.
• Current guidelines recommend permissive hypertension in the early course of acute ischemic stroke, with a goal to lower blood pressure by 15% during the first 24 hours after onset of stroke 2.
• The level of blood pressure that would mandate treatment is not well established, but consensus exists that medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 2.
• For patients undergoing intravenous thrombolysis for acute ischemic stroke, it is recommended that the blood pressure be reduced and maintained below 185 mm Hg systolic for the first 24 hours 2.

Blood Pressure Targets and Treatment

• The first-line drugs for lowering blood pressure in acute stroke patients are labetalol, nicardipine, and sodium nitroprusside 2.
• Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia may require more aggressive blood pressure management 2.
• Children with acute strokes should be managed in the same way as adults, with extrapolated lowering of blood pressures, until further evidence emerges 2.

Ongoing Research and Clinical Implications

• Persistent controversy exists regarding the benefits and risks of early, rapid lowering of elevated blood pressure in acute stroke 3.
• Accumulating evidence indicates that early blood pressure lowering can reduce haematoma expansion in intracerebral haemorrhage, but its effect on clinical outcomes is uncertain 3.
• Ongoing clinical trials aim to resolve the critical issue of hypertension management in acute stroke and provide more definitive guidance for clinicians 3.