What are the target blood pressure parameters for acute stroke management?

From the Guidelines

The target blood pressure parameters for acute stroke management should be individualized based on the stroke type and whether the patient is receiving thrombolytic therapy, with a general guideline of lowering blood pressure to <185/110 mmHg before thrombolysis and maintaining <180/105 mmHg for 24 hours after treatment in ischemic stroke patients eligible for thrombolysis. For ischemic stroke patients not receiving thrombolysis, permissive hypertension is generally allowed, with intervention typically recommended only for blood pressure exceeding 220/120 mmHg. In hemorrhagic stroke, more aggressive blood pressure control is warranted, with targets of systolic blood pressure <140-160 mmHg, as suggested by the most recent and highest quality study 1. First-line medications for acute blood pressure management include labetalol, nicardipine, and sodium nitroprusside, with the choice of agent depending on the specific clinical scenario and patient characteristics, as outlined in various guidelines 1. Key considerations in acute blood pressure management include avoiding rapid or excessive lowering of blood pressure, which can worsen cerebral ischemia, and individualizing treatment based on the patient's specific needs and comorbidities. Some of the key points to consider in the management of blood pressure in acute stroke include:

• The importance of careful blood pressure monitoring and management in the acute phase of stroke
• The need to individualize blood pressure targets based on the type of stroke and the patient's clinical characteristics
• The use of first-line medications such as labetalol, nicardipine, and sodium nitroprusside for acute blood pressure management
• The importance of avoiding rapid or excessive lowering of blood pressure, which can worsen cerebral ischemia. Overall, the management of blood pressure in acute stroke requires a careful and individualized approach, taking into account the patient's specific needs and clinical characteristics, as well as the latest evidence-based guidelines and recommendations 1.

From the FDA Drug Label

Titration 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. For more rapid blood pressure reduction, titrate every 5 minutes.

The target blood pressure parameters for acute stroke management are not explicitly stated in the provided drug label. However, it provides guidance on titration and dosage adjustment for blood pressure reduction.

• The initial infusion rate is 5 mg/hr.
• The infusion rate can be increased by 2.5 mg/hr every 15 minutes up to a maximum of 15 mg/hr.
• For more rapid blood pressure reduction, titration can be done every 5 minutes. However, the specific blood pressure parameters for acute stroke management are not mentioned in the label 2.

From the Research

Blood Pressure Parameters for Acute Stroke

The target blood pressure parameters for acute stroke management vary depending on the type of stroke and the patient's condition.

• For patients with acute ischemic stroke, blood pressure is usually left untreated up to a systolic BP (SBP) of 220 mm Hg and a diastolic BP of 120 mm Hg 3.
• However, in patients who are candidates for recombinant tissue-type plasminogen activator, blood pressure should be controlled to a level < 185/110 mm Hg before infusion and maintained at levels < 180/105 mm Hg to limit the risk of intracerebral hemorrhage (ICH) 3, 4.
• In cases of intracerebral hemorrhage, the current guidelines recommend lowering blood pressure below 160-180/100-105 mmHg if the patient is normotensive, while the target level is 180/105 mmHg in hypertensive patients 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 6.

Antihypertensive Agents

The choice of antihypertensive agent for acute stroke management is not well established, but common agents used include labetalol, nicardipine, and sodium nitroprusside 4, 7, 6.

• A study comparing labetalol, nicardipine, and hydralazine found that labetalol was the most commonly used agent, with a median time to blood pressure control of 10 minutes 4.
• Another study found that continuous-infusion labetalol and nicardipine were comparable in terms of safety and efficacy outcomes, including time at goal blood pressure and blood pressure variability 7.