What is the management of hypertension in acute cerebral stroke (CVA)?

From the Guidelines

Hypertension management in acute cerebral stroke (CVA) should be cautious, with no active lowering of blood pressure unless it is extremely high (e.g., >220/120 mmHg) or in patients receiving intravenous thrombolysis or mechanical thrombectomy.

Key Considerations

• In patients not receiving i.v. thrombolysis or mechanical thrombectomy, there is no evidence for actively lowering BP unless it is extremely high 1.
• For patients undergoing treatment with i.v. thrombolysis, BP should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1.
• In patients undergoing treatment with mechanical thrombectomy (with or without i.v. thrombolysis), BP should also be lowered to <180/105 mmHg prior to thrombectomy and maintained over the next 24 h 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.

Medication Options

• Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1 time; or Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h can be used to lower BP 1.
• If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside 1.

Monitoring and Maintenance

• Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours 1.
• Controlled blood pressure lowering during acute stroke can best be achieved with intravenous antihypertensive therapies 1.

From the Research

Management of Hypertension in Acute Cerebral Stroke (CVA)

• The management of hypertension in acute cerebral stroke is a complex issue, with varying recommendations based on the type of stroke and the patient's condition 2, 3, 4, 5, 6.
• In general, antihypertensive therapy is not recommended for patients with acute ischemic stroke, unless the blood pressure is severely elevated (>220/120 mmHg) or the patient is eligible for thrombolytic treatment (>185/110 mmHg) 2, 4.
• For patients with acute intra-cerebral hemorrhage, intensive blood pressure lowering to levels <140 mmHg for systolic blood pressure is recommended, as it has been shown to reduce the risk of hematoma expansion 2, 3.
• The blood pressure goal in acute ischemic stroke is uncertain and may depend on the time window of treatment and the use of revascularization therapy 3.
• Current guidelines support permissive hypertension in the early course of acute ischemic stroke, with a reasonable goal of lowering blood pressure by 15% during the first 24 hours after onset of stroke 4.
• First-line drugs for lowering blood pressure in acute stroke include labetalol, nicardipine, and sodium nitroprusside 4.
• Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia may override the guidelines for permissive hypertension, and a lower blood pressure may be preferred in these conditions 4.
• Further research is needed to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke 3, 5.