How to manage hypertension in a patient recovering from a hemorrhagic stroke?

Management of Hypertension in Patients Recovering from Hemorrhagic Stroke

In patients recovering from hemorrhagic stroke, blood pressure should be lowered to a target of <130/80 mmHg (<140/80 mmHg in elderly patients) using renin-angiotensin system blockers, calcium channel blockers, and diuretics as first-line agents. 1

Acute Phase Management (First 72 hours)

• During the acute phase of intracerebral hemorrhage (ICH), intensive blood pressure reduction with a systolic target <140 mmHg within 1 hour of onset is safe and may be superior to a systolic target <180 mmHg 1
• Avoid excessive BP reduction (>70 mmHg drop) in the acute phase as it may cause acute renal injury and early neurological deterioration 1
• For optimal outcomes, aim for systolic BP reductions between 30-45 mmHg over 1 hour 1
• In patients with ICH who present with SBP >220 mmHg, continuous intravenous drug infusion with close BP monitoring is reasonable to lower SBP 1
• Immediate lowering of SBP to <140 mmHg in adults with spontaneous ICH who present within 6 hours with SBP between 150-220 mmHg can be potentially harmful 1

Post-Acute Phase Management (After 72 hours)

• After the acute phase (>72 hours), when the risk of cerebral hypoperfusion decreases, initiate or reintroduce antihypertensive medications for patients with BP ≥140/90 mmHg 1, 2
• Target BP should be <130/80 mmHg (<140/80 mmHg in elderly patients) for long-term secondary prevention 1, 3
• Renin-angiotensin system (RAS) blockers (ACE inhibitors or ARBs), calcium channel blockers (CCBs), and diuretics are recommended as first-line drugs 1
• Loop diuretics should be used if eGFR <30 ml/min/1.73m² 1

Medication Selection and Monitoring

• RAS blockers are particularly beneficial as they reduce albuminuria in addition to BP control 1
• Calcium channel blockers can be added if BP target is not achieved with RAS blockers alone 1
• Monitor eGFR, microalbuminuria, and blood electrolytes regularly, especially when using RAS blockers and diuretics 1
• A 10-25% increase in serum creatinine may occur in some patients with CKD as a result of ACE inhibitor or ARB therapy 1
• Antiplatelet treatment should be carefully considered in patients with hemorrhagic stroke only in the presence of a strong indication 1

Special Considerations

• For patients with severe cerebral vessel disease, a more cautious approach with initial BP target <140/90 mmHg may be preferred due to higher risk of recurrent ischemic stroke 3
• For patients at high risk of recurrent intracerebral hemorrhage, more aggressive BP lowering (to levels <120/80 mmHg) may be beneficial 3
• Avoid non-adherence to antihypertensive treatment by implementing counseling, self-monitoring, reinforcements, and supervision 1
• Screen for secondary causes of hypertension in patients who had a hypertensive emergency 1

Common Pitfalls to Avoid

• Do not lower BP too aggressively in the first 72 hours after hemorrhagic stroke, as this can worsen cerebral ischemia due to impaired cerebral autoregulation 4
• Avoid using calcium channel blockers as monotherapy in patients with heart failure; they should only be used in case of poor BP control 1
• Do not discontinue antihypertensive medications abruptly, as this can lead to rebound hypertension 1
• Recognize that the risk of recurrent stroke is significantly higher in patients with uncontrolled hypertension 3

Following these evidence-based guidelines for BP management after hemorrhagic stroke can significantly reduce the risk of recurrent stroke and improve long-term outcomes.