What is the recommended blood pressure (BP) lowering strategy and target for a patient with acute stroke and consistently elevated blood pressures, specifically systolic blood pressure (SBP) and diastolic blood pressure (DBP), who is asymptomatic?

From the Guidelines

For a patient with acute stroke and consistently elevated blood pressure (SBP 160-190, DBP 100-110) who is asymptomatic, the best approach is to avoid aggressive BP lowering in the first few days, unless the blood pressure exceeds 220/120 mmHg, as rapid reductions in blood pressure may be harmful 1.

Initial Management

In the first 48 hours, it is crucial to maintain cerebral perfusion, and thus, blood pressure should not be lowered unless it exceeds the threshold of 220/120 mmHg, as suggested by the guidelines 1. This cautious approach is based on evidence that rapid and significant declines in blood pressure can lead to unfavorable outcomes, including increased odds of neurological worsening and higher rates of poor outcomes or death 1.

Long-term Blood Pressure Management

After the initial acute phase (2-3 days post-stroke), the focus shifts to gradually initiating antihypertensive therapy with the goal of reducing blood pressure to below 140/90 mmHg over several weeks 1. The choice of antihypertensive agent should be made on a case-by-case basis, considering the patient's overall clinical condition.

• A reasonable starting point could be a long-acting ACE inhibitor like lisinopril 5-10 mg daily or an ARB such as losartan 25-50 mg daily, which can be titrated upward every 1-2 weeks.
• Calcium channel blockers like amlodipine 5-10 mg daily are also appropriate options.
• Implementing a stepwise approach, adding a second agent if needed after optimizing the first medication, is recommended.

Monitoring and Adjustment

Home blood pressure monitoring is essential to guide the gradual reduction of blood pressure, aiming for a decrease of 10-15% in the first week and then working toward the target over 2-4 weeks 1. This measured approach balances the need to control hypertension while avoiding hypoperfusion of the ischemic penumbra, which could expand the infarct area if blood pressure is lowered too rapidly or aggressively during the acute phase.

• Regular follow-up and adjustment of antihypertensive therapy as needed are critical to achieve and maintain the target blood pressure.
• The goal is to minimize the risk of further vascular events while ensuring the best possible outcome for the patient by avoiding both uncontrolled hypertension and excessive blood pressure reduction.

From the Research

Blood Pressure Management in Acute Stroke

The patient's elevated blood pressures in the first two days of admission (SBP 160 - 190, DBP 100-110) are asymptomatic, and the best recommendation for BP lowering and BP target over the coming weeks is as follows:

• For acute ischemic stroke, the blood pressure goal is uncertain and probably depends on the time window of treatment and the use of revascularization therapy 2.
• In the hyperacute phase, a majority of patients show an elevated blood pressure, which may decrease spontaneously in a few hours and may drop further when complete recanalization is achieved 3.
• For patients undergoing intravenous thrombolysis for acute ischemic stroke, it is recommended that the blood pressure be reduced and maintained below 185 mm Hg systolic for the first 24 hours 3, 4.
• A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke 2.
• For acute ischemic stroke, current guidelines support permissive hypertension in the early course of acute ischemic stroke, and medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 4.

BP Lowering Targets

• A reasonable goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke 4.
• The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 4.
• For patients with marked elevation in blood pressure, the first-line drugs for lowering of blood pressure remain labetalol, nicardipine, and sodium nitroprusside 4.

Considerations for BP Management

• Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia would override the guidelines for permissive hypertension; a lower blood pressure would be preferred in these conditions 4.
• Children with acute strokes should be managed in the same way as adults, with extrapolated lowering of blood pressures, until further evidence emerges 4.
• Current research focuses on both hemodynamic augmentation of low blood pressures and the effects of further lowering the blood pressure after acute ischemic stroke 4, 5.