What should be the target blood pressure for a patient with an ischemic stroke?

From the Guidelines

For patients with an ischemic stroke, the target blood pressure should generally be kept below 180/105 mmHg during the acute phase (first 24-48 hours). If the patient is eligible for thrombolytic therapy with tissue plasminogen activator (tPA), blood pressure should be maintained below 185/110 mmHg before treatment and below 180/105 mmHg for the first 24 hours after treatment 1. Beyond the acute phase, the long-term target blood pressure for secondary stroke prevention is typically less than 140/90 mmHg. For patients with diabetes or chronic kidney disease, a more stringent target of less than 130/80 mmHg may be appropriate.

Key Considerations

• Blood pressure management should be individualized based on the patient's specific condition, comorbidities, and tolerance to antihypertensive medications.
• Common medications used include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide diuretics.
• Blood pressure should be lowered gradually to avoid hypoperfusion of the brain tissue surrounding the infarct area, as aggressive blood pressure reduction can potentially worsen the ischemic injury by reducing cerebral blood flow to vulnerable areas.
• In 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.
• If BP is extremely high, an initial moderate relative reduction of 10%–15% over a period of hours may be considered 1.

Blood Pressure Targets

• For patients eligible for thrombolytic therapy: <185/110 mmHg before treatment and <180/105 mmHg for the first 24 hours after treatment.
• For patients not eligible for thrombolytic therapy: no routine treatment of hypertension unless extremely high (>220/120 mmHg).
• Long-term target for secondary stroke prevention: <140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease.

Note: The most recent and highest quality study was used to make this recommendation, which is the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

From the Research

Target Blood Pressure for Ischemic Stroke

The target blood pressure for a patient with an ischemic stroke is a critical factor in determining the appropriate treatment approach. According to various studies, the following are some key points to consider:

• Before administering thrombolytic therapy, the target blood pressure should be less than 185/110 mmHg 2, 3, 4.
• After thrombolytic therapy, the target blood pressure should be less than 180/105 mmHg 3, 4.
• For patients undergoing mechanical thrombectomy, the target blood pressure before the procedure should be less than 185/110 mmHg, and during and after the procedure, the target should be less than 180/105 mmHg 5.
• However, some studies suggest that the primary goal during thrombectomy should be to prevent significant low blood pressure, with a target systolic blood pressure greater than 140 mmHg or mean arterial pressure (MAP) greater than 70 mmHg 5.
• After thrombectomy, the primary goal should be to prevent high blood pressure, with a target systolic blood pressure less than 160 mmHg or MAP less than 90 mmHg 5.

Blood Pressure Management

Blood pressure management in ischemic stroke patients is complex and depends on various factors, including the patient's individual characteristics, the severity of the stroke, and the treatment approach. Some key points to consider include:

• Elevated blood pressure is common in patients with acute ischemic stroke, and thrombolytic therapy is contraindicated in patients with a systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg 2.
• Aggressive blood pressure reduction in patients presenting with acute ischemic stroke is currently not recommended, as recent studies have shown a neutral effect of blood pressure reduction on clinical outcomes 6.
• However, in patients treated with intravenous tissue plasminogen activator, guidelines recommend a blood pressure less than 180/105 mmHg 3, 4, 6.