What are the target blood pressure parameters for stroke prevention and management?

From the Guidelines

The target blood pressure parameters for stroke prevention and management should aim for readings below 130/80 mmHg, as recommended by the most recent and highest quality study 1. This target is based on the latest guidelines and evidence, which suggest that more intensive blood pressure control can reduce the risk of stroke, particularly in high-risk patients. The following key points support this recommendation:

• The 2023 systematic review and synthesis of global stroke guidelines 1 recommends a target blood pressure of < 130/80 mm Hg for patients with stroke or TIA.
• The Canadian Stroke Best Practice Recommendations, sixth edition practice guidelines, update 2017 1 also recommend blood pressure lowering treatment to achieve a target of consistently lower than 140/90 mm Hg, with a more intensive target of < 130 mm Hg for patients with small subcortical stroke.
• Other studies, such as the 2018 implications of recent clinical trials and hypertension guidelines on stroke and future cerebrovascular research 1, also support the benefits of intensive blood pressure control in reducing the risk of stroke. Some key considerations for blood pressure management in stroke patients include:
• The need to balance the risk of cerebral hypoperfusion with the risk of excessive blood pressure
• The importance of individualizing blood pressure targets based on patient characteristics and comorbidities
• The use of first-line medications, such as labetalol, nicardipine, and clevidipine, to control blood pressure in acute stroke settings
• The role of long-term combination therapy with ACE inhibitors and thiazide diuretics to prevent recurrent strokes.

From the Research

Blood Pressure Parameters for Stroke Prevention and Management

The target blood pressure parameters for stroke prevention and management vary depending on the stage and type of stroke. The key blood pressure targets are:

• Before starting alteplase (t-PA), the target blood pressure is < 185/110 mm Hg 2
• After tPA administration, the maintenance blood pressure is < 180/105 mm Hg 2, 3
• For intracerebral hemorrhage (ICH) patients with systolic blood pressure between 150 and 220 mm Hg, acute lowering to 140 mm Hg systolic blood pressure is safe 2, 3
• For primary stroke prevention, the target blood pressure is < 140/90 mm Hg 2, 4, 5
• For recurrent stroke prevention, a blood pressure target of < 130/80 mm Hg is suggested 2, 5
• For patients with small vessel or lacunar cerebral ischemia, a reasonable blood pressure lowering target is < 130 mm Hg systolic 2

Considerations for Blood Pressure Management

When managing blood pressure in stroke patients, it is essential to consider the following:

• Control of blood pressure variability, especially in the acute phases of stroke, as it may play a role in conferring longer-term outcomes 2
• The risk of intracerebral hemorrhage (ICH) with blood pressure levels above 220/120 mm Hg 3, 4
• The benefit of antihypertensive drug therapy in both primary and secondary prevention of stroke 4, 5
• The importance of individualizing blood pressure targets based on the patient's age, comorbidities, and stroke type 5

Diastolic Blood Pressure Considerations

Recent studies have highlighted the importance of considering diastolic blood pressure levels in stroke patients:

• Low diastolic blood pressure (< 60 mm Hg) has been associated with an increased risk of composite events, including nonfatal myocardial infarction, nonfatal congestive heart failure, and death 6
• The risk of composite events persists even with reduced systolic blood pressure levels (< 140, < 130, and < 120 mm Hg) 6