Preferred Blood Pressure Medications and Dosing for Post-Stroke and Non-Stroke Patients
For post-stroke patients, a combination of an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic is the preferred initial blood pressure medication regimen, with a target blood pressure of <130/80 mmHg. 1
Post-Stroke Patients
First-Line Medication Options
- ACE inhibitors combined with a thiazide diuretic are favored in patients with ischemic stroke or TIA, as they can reduce the risk of recurrent strokes in patients with and without a diagnosis of hypertension 1
- Angiotensin receptor blockers (ARBs) may be used as an alternative to ACE inhibitors, especially in patients who do not tolerate ACE inhibitors 2
- Blood pressure treatment should be initiated as soon as possible after a stroke or TIA, or at least before discharge 1
Specific Medication Recommendations
- Lisinopril (ACE inhibitor): Initial dose 5-10 mg daily, can be titrated up to 40 mg daily 3
- Losartan (ARB): Initial dose 50 mg daily, can be increased to 100 mg daily as needed 4
- Chlorthalidone or indapamide are preferred over hydrochlorothiazide as the thiazide diuretic component due to superior efficacy and longer duration of action 1, 5
Blood Pressure Targets
- Target blood pressure for patients with stroke or TIA is <130/80 mmHg 1
- For patients with severe cerebrovascular disease, a more cautious approach with target BP <140/90 mmHg may be appropriate 6
- For patients at high risk of intracranial hemorrhage, more aggressive BP lowering to <120/80 mmHg may be beneficial 6
Non-Stroke Patients
First-Line Medication Options
- For stage 1 hypertension (140-159/90-99 mmHg): Thiazide-type diuretics for most patients; may consider ACE inhibitor, ARB, beta-blocker, or calcium channel blocker (CCB) 1
- For stage 2 hypertension (≥160/100 mmHg): Two-drug combination for most patients (usually thiazide-type diuretic plus ACE inhibitor, ARB, beta-blocker, or CCB) 1
Special Populations
- In Black patients: Thiazide-type diuretics or calcium channel blockers are preferred as first-line agents 7
- In patients with diabetes: ACE inhibitors or ARBs are recommended as first-line therapy 7
- In patients with compelling cardiac indications (e.g., previous MI, stable angina): Beta-blockers are recommended 1, 7
Blood Pressure Targets
- Current guidelines recommend a target BP of <130/80 mmHg for most adults 1, 8
- For older adults (≥60 years), some guidelines suggest a more conservative target of <150 mmHg systolic 1
Monitoring and Follow-up
- Follow-up evaluation of adherence and response to treatment should occur at monthly intervals until BP control is achieved 1
- After initiating a new or adjusted drug regimen, BP should be rechecked within 4 weeks 8
- Target BP control should be achieved within 3 months 8
Important Considerations
- An individualized approach to the selection of antihypertensive medications based on comorbidities is recommended for both post-stroke and non-stroke patients 1
- In patients with acute ischemic stroke eligible for thrombolytic therapy, BP should be lowered to <185/110 mmHg before treatment initiation and maintained <180/105 mmHg for at least 24 hours after 1
- For patients with BP <220/120 mmHg who did not receive thrombolysis, initiating antihypertensive treatment within 48-72 hours after acute ischemic stroke is not effective 1
- When BP remains uncontrolled on initial therapy, adding a medication from a different class is recommended rather than maximizing the dose of a single agent 5