Blood Pressure Target After 1 Week of Large MCA Infarct
For a patient one week after a large MCA infarct, target blood pressure should be <130/80 mm Hg, initiating or resuming antihypertensive therapy if BP remains ≥140/90 mm Hg. 1, 2
Rationale for This Target
At one week post-stroke, you are beyond the acute hyperacute phase (first 48-72 hours) where permissive hypertension is maintained, and you are now entering the subacute/secondary prevention phase where aggressive BP control reduces stroke recurrence risk. 1, 2
Key Timing Considerations
First 48-72 hours: Permissive hypertension is the standard approach—BP is not treated unless it exceeds 220/120 mm Hg in patients who did not receive thrombolysis. 3, 2 This allows for adequate cerebral perfusion to the ischemic penumbra.
After 3+ days (your patient's current timeframe): Blood pressure lowering treatment should be initiated or modified before hospital discharge. 1 The brain's autoregulation begins to recover, and the focus shifts from acute perfusion concerns to preventing recurrent stroke.
Evidence-Based Target
The <130/80 mm Hg target is supported by:
The American Heart Association/American Stroke Association guidelines recommend <130/80 mm Hg for secondary stroke prevention. 1, 2
Treating to systolic BP of 130-140 mm Hg reduces stroke recurrence (relative risk 0.76, absolute risk reduction 3.02%). 1
This target applies specifically to patients with prior stroke or TIA for long-term management. 1
Preferred Pharmacological Approach
ACE inhibitors combined with thiazide diuretics are the first-line agents for secondary stroke prevention, as they reduce stroke risk in patients with and without baseline hypertension. 1 Alternative acceptable agents include ARBs, calcium channel blockers, or thiazide diuretics alone. 1
Critical Pitfalls to Avoid in Large MCA Infarcts
Do not aggressively lower BP during the first 48-72 hours, even in large infarcts, unless BP exceeds 220/120 mm Hg. 3, 2 The concern about hemorrhagic transformation must be balanced against the risk of extending the infarct through hypoperfusion.
Avoid hypotension at all costs. After large MCA infarcts, cerebral autoregulation is impaired, making the brain especially vulnerable to arterial hypotension. 4 Blood pressure reductions during the acute phase are associated with larger infarct volumes and worse functional outcomes. 4
Monitor for the U-shaped relationship: Both excessively high and excessively low BP are associated with worse prognosis in stroke patients. 1
Monitoring Strategy
Frequent monitoring (monthly) is required until target BP is achieved and optimal therapy is established. 1
Most patients will require 2 or more antihypertensive drugs to reach goal BP. 3
When BP is >20/10 mm Hg above goal, initiate 2 drugs from the outset. 3
Special Considerations for Large MCA Infarcts
Large MCA infarcts carry risk of malignant cerebral edema, typically developing within the first 2-5 days. 5 By one week post-stroke, if the patient has not developed malignant edema requiring decompressive surgery, the focus appropriately shifts to secondary prevention with BP control. 5
Maintenance fluids should be isotonic saline, avoiding hypo-osmolar fluids that could worsen any residual edema. 3