What is the recommended blood pressure (BP) goal for patients post-stroke?

Post-Stroke Blood Pressure Goals

For long-term secondary stroke prevention, target a blood pressure of <130/80 mmHg, with treatment initiated after the acute phase (≥3 days post-stroke) in neurologically stable patients. 1, 2, 3

Long-Term BP Goals (After Acute Phase)

The ACC/AHA guidelines recommend <130/80 mmHg for all post-stroke patients, while the ESC/ESH guidelines recommend "close to 130 mmHg (or lower if tolerated)" with a diastolic target of 70-79 mmHg. 1 Both major guideline bodies converge on systolic targets near 130 mmHg, making this the most defensible target in clinical practice.

• Meta-analyses demonstrate that intensive BP lowering to <130/80 mmHg significantly reduces recurrent stroke risk by 25-30% compared to standard targets of <140/90 mmHg. 4
• The benefit is particularly strong for preventing intracranial hemorrhage recurrence. 4
• Antihypertensive therapy should be initiated or restarted before hospital discharge following stroke. 3

Acute Phase BP Management (First 72 Hours)

For Patients NOT Receiving Thrombolysis or Thrombectomy:

• Do not actively lower BP unless it exceeds 220/120 mmHg during the first 48-72 hours. 1, 2, 3
• If BP ≥220/120 mmHg, carefully reduce by approximately 15% during the first 24 hours. 1, 2, 5
• Cerebral autoregulation is impaired in acute stroke, making cerebral perfusion directly dependent on systemic BP—aggressive lowering risks extending the infarct. 2, 5

For Patients Receiving IV Thrombolysis:

• Pre-thrombolysis target: <185/110 mmHg (must achieve before administering tPA). 1, 2, 3
• Post-thrombolysis target: <180/105 mmHg for at least 24 hours. 1, 2, 3
• Use labetalol as the preferred agent, with nicardipine as an alternative. 2

For Patients Receiving Mechanical Thrombectomy:

• Target <180/105 mmHg before and for 24 hours after the procedure. 3
• During thrombectomy, avoid significant hypotension (maintain systolic BP >140 mmHg or MAP >70 mmHg). 6

Timing of Antihypertensive Initiation

• Wait ≥3 days post-stroke before initiating or reintroducing BP-lowering medications in stable patients with BP ≥140/90 mmHg. 2, 3
• No benefit exists from introducing BP medications in the first 72 hours if BP is <180/105 mmHg. 2
• Patients require monthly monitoring until target BP is achieved. 3

Preferred Medication Classes

• ACE inhibitors combined with thiazide diuretics are first-line agents, reducing stroke recurrence by approximately 30%. 3
• Acceptable alternatives include ARBs, calcium channel blockers, or thiazide diuretics alone. 3

Special Populations

Hemorrhagic Stroke (Acute ICH):

• Target systolic BP of 140-160 mmHg within 6 hours of symptom onset. 3, 5
• Avoid acute reductions >70 mmHg within 1 hour. 3, 7

Lacunar (Small Vessel) Stroke:

• A systolic BP target <130 mmHg is reasonable for secondary prevention. 3, 8

Diabetic Post-Stroke Patients:

• Target <130/80 mmHg (systolic <130 mmHg [Level C evidence], diastolic <80 mmHg [Level A evidence]). 3

Critical Pitfalls to Avoid

• Never aggressively lower BP in the acute phase (<72 hours) unless BP exceeds 220/120 mmHg or the patient is receiving thrombolysis. Doing so compromises cerebral perfusion in the ischemic penumbra. 2, 3, 5
• Avoid excessive acute drops (>70 mmHg), which cause acute kidney injury and early neurological deterioration. 2, 7
• Do not neglect to restart antihypertensives after 3 days in patients with pre-existing hypertension—this is when secondary prevention begins. 2
• Recognize the U-shaped relationship between BP and outcomes: both excessively high and low BP worsen prognosis. 3, 9, 6

Reconciling Guideline Differences

The 2019 ACC/AHA guidelines favor a universal <130/80 mmHg target, while the 2018 ESC/ESH guidelines recommend "close to 130 mmHg" with individualization. 1 The ESC/ESH approach acknowledges that elderly patients with poor vascular compliance may not tolerate aggressive lowering. 1 In clinical practice, aim for <130/80 mmHg but accept 130-140 mmHg systolic in elderly patients or those with treatment intolerance. 1