From the Guidelines
Blood pressure management in patients with ischemic stroke should prioritize maintaining cerebral perfusion, with specific targets including less than 185/110 mmHg before thrombolytic therapy and less than 180/105 mmHg for at least 24 hours after treatment, as recommended by the most recent guidelines 1. In the acute phase (first 24-72 hours), blood pressure should generally not be lowered unless it exceeds 220/120 mmHg. The following key points should be considered:
- If thrombolytic therapy with alteplase is planned, blood pressure should be reduced to below 185/110 mmHg before treatment and maintained below 180/105 mmHg for the first 24 hours after treatment, as supported by guidelines from the American College of Cardiology/American Heart Association 1.
- For patients not receiving re-perfusion treatment, blood pressure should be carefully lowered by approximately 15% during the first 24 hours after stroke onset if it is ≥220/120 mmHg, as suggested by the 2024 ESC guidelines 1.
- For long-term secondary prevention after the acute phase, the target blood pressure is typically less than 140/90 mmHg for most patients, with more aggressive targets for high-risk populations such as those with diabetes or chronic kidney disease, as indicated by previous guidelines 1. Some key medications used for blood pressure management in these patients include:
- ACE inhibitors (like ramipril or lisinopril)
- ARBs (such as candesartan or losartan)
- Calcium channel blockers (amlodipine)
- Thiazide diuretics It is essential to reduce blood pressure gradually to avoid hypoperfusion, particularly in patients with significant carotid stenosis, and to regularly monitor and adjust medications to maintain targets while avoiding side effects, as emphasized by the guidelines 1.
From the Research
Blood Pressure Targets in Ischemic Stroke
The management of blood pressure in patients with ischemic stroke is crucial for improving outcomes. According to various studies, the recommended blood pressure targets are as follows:
- For patients undergoing intravenous thrombolysis, blood pressure should be reduced and maintained below 185 mm Hg systolic for the first 24 hours 2.
- For patients not receiving thrombolysis, antihypertensive therapy is recommended only if blood pressure is ≥ 220/120 mm Hg, with a goal of 15% to 25% reduction in the first 24 hours 2, 3.
- For secondary stroke prevention, a target blood pressure of <130/80 mm Hg is recommended, although this may need to be individualized based on the patient's risk of recurrent ischemic and hemorrhagic strokes 4.
Factors Influencing Blood Pressure Management
Several factors can influence blood pressure management in patients with ischemic stroke, including:
- The presence of comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia, which may require more aggressive blood pressure lowering 2.
- The patient's age, stroke severity, and kidney function, which can affect the choice of antihypertensive therapy 3, 5.
- The risk of recurrent ischemic and hemorrhagic strokes, which can influence the target blood pressure and the aggressiveness of blood pressure lowering 4.
Antihypertensive Therapies
Various antihypertensive therapies can be used to manage blood pressure in patients with ischemic stroke, including:
- Labetalol, nicardipine, and sodium nitroprusside, which are commonly used in the acute phase of ischemic stroke 2, 5.
- Amlodipine, lisinopril, and other agents, which may be used for longer-term blood pressure management 4, 5.
- The choice of antihypertensive therapy should be individualized based on the patient's clinical characteristics and response to treatment 5.