What are the guidelines for managing hypertension in acute stroke?

From the Guidelines

Management of hypertension in acute stroke should prioritize maintaining cerebral perfusion, with blood pressure generally not lowered unless it exceeds 220/120 mmHg, except in patients receiving thrombolytic therapy or mechanical thrombectomy, where blood pressure should be maintained below 180/105 mmHg. For ischemic stroke, the beneficial effects of blood pressure reduction remain unclear, and there is no evidence for actively lowering blood pressure unless it is extremely high (e.g., >220/120 mmHg) 1. If blood pressure is extremely high, an initial moderate relative reduction of 10%–15% over a period of hours may be considered 1. In patients undergoing treatment with intravenous thrombolysis, blood pressure should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 hours 1. Similarly, in patients undergoing treatment with mechanical thrombectomy, blood pressure should also be lowered to <180/105 mmHg prior to thrombectomy and maintained over the next 24 hours 1. For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischemic stroke, initiation or reintroduction of blood pressure-lowering medication is recommended 1. Key considerations in managing hypertension in acute stroke include:

• Maintaining cerebral perfusion
• Avoiding excessive blood pressure reduction
• Individualizing treatment based on stroke type and blood pressure levels
• Continuously monitoring blood pressure and adjusting treatment as needed. The most recent guidelines from the European Society of Cardiology (2024) support this approach, emphasizing the importance of careful blood pressure management in acute ischemic stroke to balance the need to prevent further vascular damage while ensuring adequate blood flow to the ischemic penumbra 1.

From the FDA Drug Label

The time course of blood pressure decrease is dependent on the initial rate of infusion and the frequency of dosage adjustment. Nicardipine hydrochloride injection is administered by slow continuous infusion at a concentration of 0. 1 mg/mL. With constant infusion, blood pressure begins to fall within minutes. It reaches about 50% of its ultimate decrease in about 45 minutes For a gradual reduction in blood pressure, initiate therapy at a rate of 5 mg/hr. If desired blood pressure reduction is not achieved at this dose, increase the infusion rate by 2. 5 mg/hr every 15 minutes up to a maximum of 15 mg/hr, until desired blood pressure reduction is achieved.

The guidelines for managing hypertension in acute stroke using nicardipine hydrochloride injection involve:

• Initiating therapy at a rate of 5 mg/hr for a gradual reduction in blood pressure
• Increasing the infusion rate by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr until desired blood pressure reduction is achieved
• Administering the injection by slow continuous infusion at a concentration of 0.1 mg/mL 2
• Monitoring closely when titrating nicardipine hydrochloride injection in patients with congestive heart failure or impaired hepatic or renal function 2

From the Research

Guidelines for Managing Hypertension in Acute Stroke

• The management of hypertension in acute stroke is crucial, as elevated blood pressure can lead to a delay in thrombolytic therapy, which is associated with increased morbidity 3.
• Thrombolytic therapy is contraindicated in patients with a systolic blood pressure greater than 185 mmHg or diastolic blood pressure greater than 110 mmHg 3.
• There is currently insufficient evidence to support the use of a specific antihypertensive agent in this setting, but labetalol, nicardipine, and hydralazine are commonly used 3.
• Adequate initial dosing of antihypertensive treatment has the potential to reduce time to blood pressure control and possibly time to alteplase therapy 3.

Predictors of Non-Thrombolysis in Acute Ischemic Stroke

• Previous stroke, arriving between 3 hours and 4.5 hours after onset, or having mild symptoms are significant predictors of not receiving thrombolytic treatment in patients with acute ischemic stroke 4.
• Older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, and NIH Stroke Scale score <5 are also associated with failure to treat with tPA 5.

Hemorrhagic Conversion of Acute Ischemic Stroke

• Hemorrhagic transformation is a serious complication of ischemic stroke, and current treatment options, including endovascular thrombectomy and thrombolytic therapy, are linked with increased risks of hemorrhagic conversion 6.
• The diagnosis and timely management of patients with hemorrhagic conversion is critically important to patient outcomes 6.

Thrombolytic Strategies for Ischemic Stroke

• Intravenous thrombolysis has revolutionized the care of patients with acute ischemic stroke, but mechanical thrombectomy has improved functional outcome in stroke patients over intravenous thrombolysis alone 7.
• New thrombolytic strategies, such as tenecteplase, and combined strategies with mechanical thrombectomy are being developed to further improve functional outcome in stroke 7.