What should the goal blood pressure be after an acute stroke?

Blood Pressure Management After Acute Stroke

For patients after acute ischemic stroke, the target blood pressure should be <130/80 mmHg for long-term secondary stroke prevention. 1

Immediate Post-Stroke Blood Pressure Management

Blood pressure management in the acute phase of stroke requires a careful approach that balances the risks of both hypertension and hypotension:

For patients NOT receiving thrombolysis or thrombectomy:

• Do not actively lower BP unless extremely elevated (>220/120 mmHg) 1, 2
• If BP >220/120 mmHg, reduce BP by approximately 15% during the first 24 hours 1
• Avoid rapid or excessive BP lowering as this may exacerbate existing ischemia 1

For patients receiving thrombolysis or thrombectomy:

• Lower BP to <185/110 mmHg before treatment 1, 2
• Maintain BP <180/105 mmHg for at least 24 hours after treatment 1, 2
• Monitor BP every 15 minutes during treatment and for 2 hours after, then every 30 minutes for 6 hours, and hourly for 16 hours 1

Transitioning to Long-Term BP Management

Timing of antihypertensive therapy initiation:

• For patients with pre-existing hypertension who are neurologically stable, restart antihypertensive medications after 24 hours 1
• For previously untreated patients with established BP ≥140/90 mmHg, start antihypertensive treatment a few days after the stroke 1

Long-term BP targets:

• Target BP <130/80 mmHg for secondary stroke prevention 1
• For patients with lacunar stroke, a target systolic BP <130 mmHg may be particularly beneficial 1

Medication Selection

The choice of antihypertensive agents should be guided by:

• First-line options: 1

  • Thiazide diuretics
  • ACE inhibitors
  • ARBs
  • Combination of thiazide diuretic plus ACE inhibitor

• For acute BP lowering when needed:

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

Important Considerations and Pitfalls

• Avoid hypotension: Excessive drops in BP can reduce cerebral perfusion and worsen outcomes 1, 2
• Blood pressure variability: Minimize fluctuations in BP as these are associated with worse outcomes 3
• Individualize based on comorbidities: Consider cardiac, renal, and other conditions when selecting medications 1
• U-shaped relationship: Both very high and very low BP are associated with worse outcomes in acute ischemic stroke 4, 5

Monitoring and Follow-up

• Regular BP monitoring during hospitalization and after discharge
• Assess lipid levels, diabetes control, and other vascular risk factors
• Implement lifestyle modifications including weight management, physical activity, smoking cessation, and moderate alcohol consumption 1

The evidence strongly supports a target BP of <130/80 mmHg for long-term secondary stroke prevention, though the approach to reaching this target must be carefully managed, particularly in the first few days after stroke.