What is the most appropriate initial treatment for a 68-year-old male patient with acute stroke, National Institutes of Health Stroke Scale (NIHSS) score of 11, and hypertension (blood pressure 210/100 mm Hg), who is a candidate for intravenous (IV) Alteplase (tissue plasminogen activator, t-PA) therapy?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Article Review Status
Submitted
Under Review
Approved

Last updated: June 18, 2025 • View editorial policy

From the Guidelines

The most appropriate initial treatment for this 68-year-old male stroke patient with an NIHSS score of 11 and hypertension is to first lower his blood pressure to below 185/110 mm Hg before administering IV Alteplase, which can be achieved with IV labetalol (10-20 mg over 1-2 minutes, may repeat once) or nicardipine infusion (5 mg/hour, titrate up by 2.5 mg/hour every 5-15 minutes, maximum 15 mg/hour) as recommended by the American Heart Association guidelines 1.

The patient's blood pressure is 210/100 mm Hg, which is above the recommended threshold for administering IV Alteplase. According to the guidelines, blood pressure should be lowered to below 185/110 mm Hg before administering thrombolytic therapy to minimize the risk of intracranial hemorrhage. The use of IV labetalol or nicardipine infusion is recommended to achieve this goal.

Some key points to consider in the management of this patient include:

  • Monitoring blood pressure closely during and after Alteplase infusion to ensure that it remains below the recommended threshold
  • Administering IV Alteplase at a dose of 0.9 mg/kg (maximum dose 90 mg) with 10% given as an initial bolus over 1 minute and the remaining 90% infused over 60 minutes
  • Being prepared to reinstitute aggressive antihypertensive therapy if systolic BP exceeds 180 mm Hg or diastolic BP exceeds 105 mm Hg during or after infusion

The American Stroke Association guidelines also 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 intracranial hemorrhage is identified 2. In this case, the patient's blood pressure is above the recommended threshold for administering IV Alteplase, and therefore, it should be lowered before initiating thrombolytic therapy.

The patient's NIHSS score of 11 indicates a moderate to severe stroke, making him an appropriate candidate for thrombolytic therapy, which has been shown to improve neurological outcomes when administered within the appropriate time window 1.

In terms of specific treatment options, the guidelines recommend the use of IV labetalol or nicardipine infusion to lower blood pressure before administering IV Alteplase 1. The dose of IV Alteplase should be calculated based on the patient's weight, with a maximum dose of 90 mg 1.

Overall, the key priority in the management of this patient is to lower his blood pressure to below 185/110 mm Hg before administering IV Alteplase, and to closely monitor his blood pressure during and after infusion to minimize the risk of intracranial hemorrhage.

From the FDA Drug Label

Blood pressure should be monitored and managed as follows: For patients with blood pressure > 185 mmHg systolic or > 110 mmHg diastolic, the blood pressure should be lowered to below these limits before Alteplase administration (e.g., with intravenous labetalol or nicardipine) [reference_id: not provided, but typically found in the Alteplase label under the section for administration or precautions for acute ischemic stroke treatment].

The most appropriate initial treatment for this patient is to hold Alteplase and administer labetalol 10 mg IV to lower the blood pressure to a systolic value of 180 mm Hg or less, then recheck BP in 5-10 minutes. If necessary, repeat labetalol as needed or use nicardipine drip to maintain blood pressure within the recommended range for Alteplase administration.

  • Key considerations: + Blood pressure management is crucial before administering Alteplase. + The goal is to achieve a systolic blood pressure of 180 mm Hg or less. + Labetalol or nicardipine can be used to lower blood pressure. + Alteplase should not be administered until blood pressure is adequately managed. 3 and 4 do not directly address blood pressure management in the context of Alteplase administration for acute ischemic stroke.

From the Research

Initial Treatment for Acute Stroke Patient with Hypertension

The patient in question has a blood pressure of 210/100 mm Hg, which is above the recommended threshold for intravenous (IV) Alteplase therapy. According to the guidelines, the systolic blood pressure should be less than 185 mm Hg and the diastolic blood pressure should be less than 110 mm Hg before administering Alteplase.

Antihypertensive Treatment Options

The following options are available for antihypertensive treatment:

  • Labetalol: a commonly used antihypertensive medication for acute stroke patients 5, 6
  • Nicardipine: another antihypertensive medication used in acute stroke patients 5, 6
  • Hydralazine: an antihypertensive medication that can be used in acute stroke patients 5, 7

Most Appropriate Initial Treatment

Based on the available evidence, the most appropriate initial treatment for this patient would be to hold Alteplase and administer labetalol 10 mg IV to reduce the blood pressure to a safe level for Alteplase therapy 5. The blood pressure should be rechecked in 5-10 minutes, and labetalol can be repeated as needed or a nicardipine drip can be started if necessary.

Key Considerations

  • The goal is to reduce the systolic blood pressure to less than 185 mm Hg and the diastolic blood pressure to less than 110 mm Hg before administering Alteplase 5, 7
  • Labetalol is a commonly used antihypertensive medication for acute stroke patients, but it can cause profound hypotension in some cases 8
  • The choice of antihypertensive medication and the dosing strategy may depend on the individual patient's characteristics and the clinical scenario 5, 6, 9, 7

References

Research

Time to Blood Pressure Control Before Thrombolytic Therapy in Patients With Acute Ischemic Stroke: Comparison of Labetalol, Nicardipine, and Hydralazine.

The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses, 2015

Research

Continuous-Infusion Labetalol vs Nicardipine for Hypertension Management in Stroke Patients.

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 2018

Research

Delay to Tissue Plasminogen Activator in Hypertensive Stroke Patients: An Analysis of Delay Duration Across Agents.

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 2020

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.