What is the blood pressure (BP) goal after a stroke treated with Tissue Plasminogen Activator (tPA) (Tenecteplase (TNK))?

From the Guidelines

The blood pressure goal after TNK (tenecteplase) administration for stroke is to maintain systolic blood pressure below 180 mmHg and diastolic blood pressure below 105 mmHg for the first 24 hours. This recommendation is based on the most recent guidelines from the European Society of Cardiology, published in 2024 1. The guidelines emphasize the importance of proactive management of severe hypertension in patients treated with i.v. thrombolysis or mechanical thrombectomy, as they have an increased risk of reperfusion injury and intracranial haemorrhage.

Key Considerations

• Blood pressure should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1.
• Patients with acute ischaemic stroke and a BP of <180/105 mmHg in the first 72 h after stroke do not seem to benefit from the introduction or reintroduction of BP-lowering medication 1.
• For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischaemic stroke, initiation or reintroduction of BP-lowering medication is recommended 1.

Monitoring and Management

• Blood pressure should be monitored frequently, typically every 15 minutes for the first 2 hours, then every 30 minutes for the next 6 hours, and hourly thereafter for the first 24 hours.
• If blood pressure exceeds the target, antihypertensive medications such as labetalol or nicardipine should be administered.
• Aggressive blood pressure control is crucial because elevated blood pressure after thrombolytic therapy increases the risk of symptomatic intracranial hemorrhage, which is the most serious complication of TNK treatment.

Rationale

The rationale for this recommendation is based on the balance between the need to reduce the risk of reperfusion injury and intracranial haemorrhage, and the need to maintain cerebral perfusion in the ischemic penumbra. The guidelines from the European Society of Cardiology provide the most up-to-date and evidence-based recommendations for the management of blood pressure in patients with acute ischaemic stroke treated with TNK.

From the Research

Blood Pressure Goals after Stroke Treated with tPA

The ideal blood pressure (BP) goal after a stroke treated with Tissue Plasminogen Activator (tPA) is a topic of interest in the medical field.

• The American Heart Association recommends that blood pressure should be below 185/110 mmHg before administering tPA 2.
• However, there is evidence to suggest that aggressive blood pressure lowering before tPA therapy may not be associated with a higher rate of hemorrhage or poor outcome 2.
• The studies do not provide a specific blood pressure goal after tPA administration, but rather focus on the safety and efficacy of tPA therapy in patients with acute ischemic stroke 3, 4, 5, 6.
• It is worth noting that the blood pressure goal may vary depending on individual patient factors, such as the presence of hypertension or other comorbidities.

Key Findings

• A study published in the Archives of Neurology found that patients with acute ischemic stroke who required blood pressure lowering before tPA therapy had higher baseline blood glucose concentrations, incidence of hypertension, and National Institutes of Health Stroke Scale scores 2.
• Another study published in The New England Journal of Medicine found that tPA therapy improved clinical outcome at three months, despite an increased incidence of symptomatic intracerebral hemorrhage 3.
• A systematic review and meta-analysis published in the Journal of Stroke and Cerebrovascular Diseases found that low-dose tPA was comparable to standard-dose tPA in improving neurologic function and reducing mortality in patients with acute ischemic stroke, while also reducing the incidence of symptomatic intracranial hemorrhage 6.

Blood Pressure Management

• The management of blood pressure in patients with acute ischemic stroke is crucial, as elevated blood pressure can increase the risk of hemorrhagic transformation 5.
• The use of antihypertensive agents, such as nicardipine or labetalol, may be necessary to control blood pressure in some patients 2.
• However, the optimal blood pressure goal and management strategy after tPA administration remain unclear and require further study.