From the Guidelines
Permissive hypertension should be maintained for at least 24 hours after an acute ischemic stroke, with blood pressure generally not treated unless it exceeds 220/120 mmHg, or 180/105 mmHg in patients receiving thrombolytic therapy (tPA) 1. When considering the management of blood pressure after a cerebrovascular accident (CVA) or stroke, it is crucial to prioritize the maintenance of cerebral perfusion pressure in the ischemic penumbra surrounding the stroke.
- The goal is to avoid lowering blood pressure too aggressively early after stroke, as this can reduce blood flow to vulnerable brain tissue and potentially worsen neurological outcomes.
- According to the guidelines for the early management of patients with acute ischemic stroke, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke, but only if the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg 1.
- For patients receiving thrombolytic therapy (tPA), the threshold for treatment is lower, with blood pressure above 180/105 mmHg requiring intervention 1.
- The use of titratable medications like labetalol or nicardipine is recommended for gradual reduction of blood pressure, allowing for maintenance of cerebral perfusion pressure in the ischemic penumbra.
- After the initial 24-hour period, blood pressure can be gradually normalized as the risk of extending the infarct decreases and the benefit of preventing recurrent stroke becomes more important.
- It is essential to note that the management of blood pressure after a stroke should be individualized, taking into account the patient's specific clinical context and comorbidities, as well as the potential risks and benefits of different treatment strategies 1.
From the Research
Recommended Duration of Permissive Hypertension
The recommended duration of permissive hypertension after a cerebrovascular accident (CVA) or stroke is not explicitly stated in the provided studies. However, the following guidelines are recommended:
- Permissive hypertension is recommended 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.
- For patients with marked elevation in blood pressure, treatment is recommended if the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 2, 3, 4, 5.
- 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.
- The use of predictable and titratable medications that judiciously reduce (approximately 10% to 15%) the initial presenting mean arterial pressure is recommended in situations where antihypertensive treatment is warranted 3.
Key Considerations
- Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia would override the guidelines for permissive hypertension; a lower blood pressure would be preferred in these conditions 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.
- The optimal management of blood pressure in the first 24 hours of ischemic stroke remains a controversial topic, and future research is needed to define optimal blood pressure goals, likely on an individual basis 3, 5.