From the Guidelines
The blood pressure goal after a cerebrovascular accident (stroke) should be to maintain blood pressure below 140/90 mmHg for most patients, with more aggressive control targeting systolic BP below 140 mmHg in hemorrhagic stroke. In the acute phase following a stroke (first 72 hours), management differs based on whether the stroke is ischemic or hemorrhagic. For ischemic stroke, blood pressure should generally not be aggressively lowered unless it exceeds 220/120 mmHg or if thrombolytic therapy is planned (then keep below 180/105 mmHg) 1. For hemorrhagic stroke, more aggressive BP control is recommended, targeting systolic BP below 140 mmHg 1. After the acute phase, long-term BP management should aim for less than 140/90 mmHg for secondary stroke prevention. Some key points to consider in blood pressure management after stroke include:
- Avoiding aggressive lowering of blood pressure in the acute phase unless necessary, as rapid and steep reductions in blood pressure might be harmful 1
- Using first-line medications such as ACE inhibitors, ARBs, thiazide diuretics, or calcium channel blockers to achieve target blood pressure levels 1
- Regular monitoring and gradual medication adjustments to avoid hypotension, which could potentially compromise cerebral perfusion, especially in patients with significant carotid stenosis 1
- Considering the patient's individual characteristics, such as preexisting hypertension and neurological stability, when deciding on blood pressure management 1 It's essential to note that the evidence is not always clear-cut, and the management of blood pressure after stroke should be individualized based on the patient's specific needs and circumstances, prioritizing morbidity, mortality, and quality of life as the outcome 1.
From the Research
Blood Pressure Goals After a Cerebrovascular Accident (Stroke)
- The optimal blood pressure (BP) goal after a stroke is still a topic of debate, with different recommendations for different types of stroke [(2,3,4)].
- For patients with acute intracerebral hemorrhage (ICH), the evidence supports immediate BP lowering, targeting a systolic BP of 140 mmHg [(2,4)].
- For patients with acute ischemic stroke, the BP goal is uncertain and may depend on the time window of treatment and the use of revascularization therapy [(2,4)].
- In patients treated with intravenous tissue plasminogen activator, guidelines recommend a BP of <180/105 mmHg 2.
- 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 5.
- A systolic blood pressure goal of <130/80 mmHg is recommended for secondary stroke prevention, but the target BP needs to be individualized 6.
- Current guidelines support permissive hypertension in the early course of acute ischemic stroke, with a reasonable goal of lowering blood pressure by 15% during the first 24 hours after onset of stroke 5.
- The level of blood pressure that would mandate treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 5.