What is the recommended blood pressure target for a patient with acute ischemic stroke on the 2nd day post-stroke who is not eligible for thrombolysis or thrombectomy?

Blood Pressure Management in Acute Ischemic Stroke on Day 2 Post-Stroke (Not Eligible for Reperfusion Therapy)

For patients with acute ischemic stroke on day 2 who are not eligible for thrombolysis or thrombectomy, blood pressure should not be actively lowered unless it exceeds 220/120 mmHg, in which case it should be carefully reduced by approximately 15% during the first 24 hours after stroke onset. 1

General Principles of BP Management in Acute Ischemic Stroke

• In acute ischemic stroke patients not receiving reperfusion therapy, there is no evidence supporting routine blood pressure reduction unless BP is extremely elevated (>220/120 mmHg) 1
• Cerebral autoregulation is often impaired in acute stroke, making cerebral perfusion directly dependent on systemic blood pressure 1
• Permissive hypertension is generally recommended in the first 72 hours after stroke onset to maintain adequate cerebral perfusion 1, 2

Specific BP Targets Based on Clinical Scenario

For patients NOT receiving reperfusion therapy (thrombolysis or thrombectomy):

• If BP <220/120 mmHg: No antihypertensive treatment is recommended during the first 48-72 hours 1
• If BP ≥220/120 mmHg: Carefully lower BP by approximately 15% during the first 24 hours 1
• Avoid rapid or excessive BP reduction as this may exacerbate existing ischemia, particularly with arterial occlusions 1

For comparison - patients receiving reperfusion therapy (not applicable to this case):

• Prior to thrombolysis: Lower BP to <185/110 mmHg 1
• During and after thrombolysis/thrombectomy: Maintain BP <180/105 mmHg for at least 24 hours 1

Timing of Antihypertensive Therapy Initiation

• For patients with BP <180/105 mmHg: No benefit from introducing or reintroducing BP-lowering medication in the first 72 hours 1
• For stable patients who remain hypertensive (≥140/90 mmHg): Initiate or reintroduce BP-lowering medication ≥3 days after stroke onset 1
• Starting or restarting antihypertensive therapy during hospitalization is reasonable in neurologically stable patients with BP >140/90 mmHg 1

Pharmacological Considerations

• When BP reduction is necessary, choose agents that avoid precipitous falls in blood pressure 1
• First-line medications for acute BP management include labetalol, nicardipine, and sodium nitroprusside 2
• Avoid excessive acute drops in systolic BP (>70 mmHg) as this may cause acute renal injury and early neurological deterioration 1

Long-term BP Management After Acute Phase

• For patients with ischemic stroke and an indication for BP lowering, antihypertensive therapy should be commenced before hospital discharge 1
• BP targets for secondary stroke prevention may be lower (<130/80 mmHg) after the acute phase has resolved 1

Common Pitfalls to Avoid

• Lowering BP too aggressively in the acute phase, which can compromise cerebral perfusion 1
• Failing to recognize that BP often decreases spontaneously in the first few hours after stroke 3
• Neglecting to restart antihypertensive medications after the acute phase (≥3 days) in patients with pre-existing hypertension 1
• Using medications that cause rapid BP reduction, which may worsen outcomes 1