From the Guidelines
Blood pressure management in the first 48 hours after stroke should prioritize careful consideration of stroke type, with a focus on maintaining optimal cerebral perfusion while minimizing the risk of hypertension-related complications. For ischemic stroke, the guidelines recommend maintaining systolic blood pressure (SBP) below 220 mmHg and diastolic blood pressure (DBP) below 120 mmHg initially, unless the patient is receiving thrombolytic therapy, in which case BP should be kept below 180/105 mmHg 1. In patients with ischemic stroke not receiving re-perfusion treatment and BP of ≥220/110 mmHg, BP should be carefully lowered by approximately 15% during the first 24 h after stroke onset 1. For intracerebral hemorrhage, immediate BP lowering to a systolic target of 140-160 mmHg should be considered to prevent hematoma expansion and improve functional outcome 1. Key considerations in blood pressure management after stroke include:
- Maintaining euvolemia and avoiding hypotension (SBP <120 mmHg)
- Avoiding aggressive BP reduction, which may worsen cerebral ischemia by reducing perfusion to the penumbra area
- Using titratable IV medications like labetalol, nicardipine, or clevidipine when treatment is needed
- Gradually transitioning to oral antihypertensives after 48 hours while monitoring for neurological deterioration 1. The most recent guidelines from 2024 recommend a cautious approach to blood pressure management in the acute phase of stroke, prioritizing the balance between minimizing hypertension-related complications and maintaining adequate cerebral perfusion 1.
From the Research
Blood Pressure Control in the First 48 Hours of STROKE
- The management of blood pressure in the first 48 hours of stroke is crucial to prevent further complications and improve outcomes 2, 3, 4.
- In the hyperacute phase, most patients show elevated blood pressure due to sympathetic hyperactivity or physiological response to tissue ischemia, which may decrease spontaneously or with complete recanalization 2.
- The American Heart Association recommends that elevated blood pressure be left untreated up to a systolic BP of 220 mmHg and a diastolic BP of 120 mmHg, unless the patient is a candidate for thrombolytic therapy or has other specific conditions 2, 4.
Blood Pressure Targets for Different Stroke Types
- For patients with ischemic stroke who are candidates for recombinant tissue-type plasminogen activator, blood pressure should be controlled to a level < 185/110 mmHg before infusion and maintained at levels < 180/105 mmHg to limit the risk of intracerebral hemorrhage (ICH) 2.
- In cases of intracerebral hemorrhage, blood pressure reduction to a systolic BP of 140 mmHg is recommended, as rapid reduction is generally well-tolerated without a risk of neurological worsening 2, 4.
- For patients undergoing endovascular thrombectomy, the optimal intra- and post-procedural blood pressure target has not been clearly identified, but expert opinion suggests that systolic BP may be reduced only to 120-140 mmHg after successful reperfusion therapy 2.
Comparison of Antihypertensive Agents
- Labetalol and nicardipine are commonly used antihypertensive agents in the management of elevated blood pressure following an acute stroke 5, 6.
- Studies have shown that nicardipine may have a superior therapeutic response compared to labetalol in achieving goal blood pressure, with better maintenance of blood pressure and less variability 5.
- However, another study found that continuous-infusion labetalol and nicardipine had comparable safety and efficacy outcomes, including time at goal blood pressure and blood pressure variability 6.