What are the recommended blood pressure parameters for a patient with stroke?

Blood Pressure Management in Acute Stroke

**For patients with acute ischemic stroke, blood pressure should be maintained <185/110 mmHg before thrombolysis and <180/105 mmHg for at least 24 hours after thrombolytic therapy.** For patients not receiving reperfusion therapy with BP >220/120 mmHg, BP should be lowered by approximately 15% during the first 24 hours after stroke onset 1.

Blood Pressure Management Based on Stroke Type and Treatment

Ischemic Stroke with Thrombolysis/Thrombectomy

• Pre-treatment target: <185/110 mmHg before initiating thrombolysis 1
• Post-treatment target: <180/105 mmHg for at least 24 hours after treatment 1
• Monitoring frequency: Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1

Ischemic Stroke without Reperfusion Therapy

• For BP <220/120 mmHg: No immediate BP-lowering treatment is recommended within first 48-72 hours 1
• For BP ≥220/110 mmHg: Lower BP by approximately 15% during first 24 hours 1
• Avoid rapid or excessive BP reduction as it may exacerbate ischemia 1

Intracerebral Hemorrhage (ICH)

• For systolic BP between 150-220 mmHg: Target systolic BP of 140-160 mmHg 1
• For systolic BP >220 mmHg: Use continuous IV infusion with close monitoring 1
• Avoid acute BP reduction >70 mmHg from initial levels within 1 hour 1

Medication Options for Acute BP Management

For Patients Eligible for Thrombolysis/Thrombectomy

• First-line options:

  • Labetalol: 10-20 mg IV over 1-2 minutes, may repeat once 1
  • Nicardipine: 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h 1

• For refractory hypertension:

  • If BP not controlled or diastolic BP >140 mmHg, consider sodium nitroprusside 1

Important Considerations and Pitfalls

1. Avoid excessive BP lowering:

   • Cerebral autoregulation is impaired in the ischemic penumbra
   • Rapid or excessive BP reduction may worsen ischemia or induce new ischemic areas 1

2. Post-acute management:

   • For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after acute ischemic stroke, initiation or reintroduction of BP-lowering medication is recommended 1
   • Restarting antihypertensive therapy during hospitalization is reasonable for neurologically stable patients with BP >140/90 mmHg 1

3. Special populations:

   • For pre-eclampsia or eclampsia with hypertensive crisis: IV labetalol or nicardipine and magnesium 1
   • For pre-eclampsia with pulmonary edema: IV nitroglycerin 1

Evidence Quality and Controversies

The recommendations for BP management in acute stroke are based on strong evidence from multiple guidelines. The 2024 ESC guidelines 1 provide the most recent recommendations, consistent with earlier guidelines from AHA/ASA 1.

There is a notable J-shaped or U-shaped relationship between admission BP and outcomes in ischemic stroke, with optimal SBP ranging from 121-200 mmHg and DBP from 81-110 mmHg 1, 2. This explains the conservative approach to BP lowering in non-thrombolysis patients.

While aggressive BP lowering is beneficial in hemorrhagic stroke (targeting SBP 140 mmHg) 3, 2, the evidence for aggressive BP reduction in ischemic stroke without reperfusion therapy remains inconclusive, with most trials showing neutral effects 3.

The optimal BP management after successful reperfusion therapy remains an area of ongoing research, with some experts suggesting SBP reduction to 120-140 mmHg may be appropriate after successful reperfusion 4.