Blood Pressure Goals After Tenecteplase for Acute Ischemic Stroke
Maintain blood pressure <180/105 mm Hg for at least the first 24 hours after tenecteplase administration. 1
Pre-Treatment BP Requirements
Before administering tenecteplase (or any IV thrombolytic), you must achieve and confirm:
- Systolic BP <185 mm Hg AND diastolic BP <110 mm Hg 1
- If BP cannot be lowered and stabilized below these thresholds, do not give tenecteplase 1
Post-Thrombolysis BP Management Algorithm
First 24 Hours (Critical Period)
Target: Maintain BP <180/105 mm Hg 1
Monitoring frequency: 1
- Every 15 minutes for the first 2 hours
- Every 30 minutes for hours 2-8
- Every hour for hours 8-24
Treatment Thresholds During First 24 Hours
If systolic BP 180-230 mm Hg OR diastolic BP 105-120 mm Hg: 1
- Labetalol 10 mg IV bolus, then continuous infusion 2-8 mg/min; OR
- Nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5-15 min (max 15 mg/h); OR
- Clevidipine 1-2 mg/h IV, double dose every 2-5 min until target reached (max 21 mg/h)
If diastolic BP >140 mm Hg despite above measures: 1
- Consider IV sodium nitroprusside (though generally avoided in stroke due to ICP concerns) 2
Rationale for Strict BP Control
The <180/105 mm Hg target after thrombolysis is based on:
- Hemorrhagic transformation risk: Large observational studies demonstrate that elevated BP during the first 24 hours after IV thrombolysis significantly increases symptomatic intracranial hemorrhage risk 1
- Trial inclusion criteria: These BP cutoffs were used in pivotal alteplase trials and represent the evidence base for safe thrombolytic administration 1
After the First 24 Hours
For neurologically stable patients with BP >140/90 mm Hg: 1
- Starting or restarting antihypertensive therapy is reasonable to improve long-term BP control
- This typically begins after 24 hours if the patient remains stable
Critical Pitfalls to Avoid
Avoid precipitous BP drops: 1, 3
- Cerebral autoregulation is impaired in acute stroke
- Rapid BP reduction can compromise perfusion to ischemic penumbra
- Lower BP gradually and monitor neurological status continuously
Do not undertreate hypertension in the post-thrombolysis period: 1
- The risk of hemorrhagic transformation increases linearly with BP elevation above 180/105 mm Hg
- Aggressive monitoring and treatment are essential during the first 24 hours
Avoid excessive BP lowering below target: 3, 4
- Systolic BP drops >70 mm Hg can cause acute renal injury and neurological deterioration
- Target the guideline-recommended range, not lower
Special Considerations
If mechanical thrombectomy is also planned: 1
- Maintain BP <185/110 mm Hg before the procedure if thrombolytics were given
- Post-procedure BP management follows the same <180/105 mm Hg target for 24 hours
Tenecteplase vs. alteplase: 1
- While most guidelines reference alteplase, the same BP management principles apply to tenecteplase
- Both are tissue plasminogen activators with similar hemorrhagic risk profiles