What is the target blood pressure (BP) level in the acute phase following an ischemic stroke?

From the Guidelines

The target blood pressure level in the acute phase following an ischemic stroke should be permissive hypertension, generally allowing systolic blood pressure up to 220 mmHg and diastolic blood pressure up to 120 mmHg without intervention, unless the patient received thrombolytic therapy or has other compelling indications. In patients not receiving i.v. thrombolysis or mechanical thrombectomy, there is no evidence for actively lowering BP unless it is extremely high (e.g. >220/120 mmHg) 1. If BP is extremely high, an initial moderate relative reduction of 10%–15% over a period of hours may be considered 1. In contrast, patients who are treated with i.v. thrombolysis or mechanical thrombectomy (or both) should have more proactive management of severe hypertension, with BP lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1. Some key points to consider in the management of blood pressure in acute ischemic stroke include:

• Blood pressure should only be lowered if it exceeds the thresholds, if there are other compelling indications, or if the patient received thrombolytic therapy.
• For patients who received thrombolysis with tPA, blood pressure should be maintained below 180/105 mmHg for at least 24 hours after treatment.
• After the acute period (typically 48-72 hours), gradual blood pressure reduction can begin, with a general target of <140/90 mmHg for most patients. The permissive hypertension approach is recommended because the ischemic penumbra surrounding the stroke core depends on adequate perfusion pressure to maintain blood flow, and lowering blood pressure too aggressively could extend the area of infarction 2. When treatment is necessary, intravenous labetalol or nicardipine are preferred agents for acute management. It is essential to note that the management of blood pressure in acute ischemic stroke should be individualized, taking into account the patient's specific clinical context and any comorbid conditions that may require acute antihypertensive treatment 1, 2.

From the Research

Target Blood Pressure Level in Acute Ischemic Stroke

• The optimal target blood pressure level in the acute phase of ischemic stroke is not well established, with different studies suggesting various thresholds 3, 4, 5, 6, 7.
• Current guidelines recommend permissive hypertension in the early course of acute ischemic stroke, with a goal to lower blood pressure by 15% during the first 24 hours after onset of stroke, but only if the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 3.
• For patients undergoing intravenous thrombolysis, it is recommended to reduce and maintain blood pressure below 185 mm Hg systolic for the first 24 hours 3, 6.
• Some studies suggest that a systolic blood pressure goal of 140 mm Hg to 159 mm Hg and diastolic blood pressure goal of 90 mm Hg to 99 mm Hg may be associated with good neurological recovery and low risk of neurological deterioration 7.
• However, other studies indicate that both high and low blood pressures can have detrimental effects on neurological outcomes, and that the relationship between blood pressure and clinical outcomes is likely J- or U-shaped 4, 5.

Blood Pressure Management in Acute Ischemic Stroke

• The choice of antihypertensive treatment should be adjusted to different clinical and blood pressure parameters, taking into account factors such as diastolic blood pressure, kidney function, and risk of hyponatremia 4.
• Labetalol, nicardipine, and sodium nitroprusside are commonly used as first-line treatments for lowering blood pressure in acute ischemic stroke 3, 6.
• Machine learning techniques may be useful in developing decision support tools for improving blood pressure management in acute ischemic stroke 4.