Target Blood Pressure on Day 5 Post-Ischemic Stroke
For a patient on day 5 post-ischemic stroke, target blood pressure should be <140/90 mmHg, with initiation or reintroduction of antihypertensive medications if BP remains ≥140/90 mmHg. 1
Rationale and Timeline
By day 5, you are well beyond the hyperacute phase (first 24-72 hours) where permissive hypertension is recommended. The acute phase guidelines that advocate withholding treatment for BP <220/120 mmHg apply only to the first 48-72 hours. 2, 1
Key Transition Points:
First 24-72 hours: Permissive hypertension is appropriate unless BP ≥220/120 mmHg (or patient received thrombolysis). 2, 1
After 3+ days (including day 5): Transition to secondary prevention targets of <140/90 mmHg for stable patients who remain hypertensive. 1
Specific BP Targets for Day 5
Standard target: <140/90 mmHg for most ischemic stroke patients 1
Enhanced target considerations:
- For patients with small vessel (lacunar) stroke: <130 mmHg systolic is reasonable 1, 3
- For diabetic patients: <130/80 mmHg (systolic <130 mmHg [Evidence Level C], diastolic <80 mmHg [Evidence Level A]) 1
- For patients with atherosclerotic disease: <130/80 mmHg may be reasonable 1
Critical Caveats for Intracranial Atherosclerosis
If the stroke was caused by intracranial atherosclerotic stenosis (>50% stenosis of ICA or MCA), avoid aggressive BP lowering below 140 mmHg systolic. A randomized trial demonstrated that intensive BP control (target <120 mmHg) in the subacute phase (7-42 days post-stroke) increased ischemic lesion volume compared to modest control (target <140 mmHg). 4 This represents a critical exception where overly aggressive BP reduction may be harmful.
Medication Management
Blood pressure lowering treatment should be initiated or modified before hospital discharge. 1 The preferred regimen for long-term secondary prevention includes:
- First-line: ACE inhibitors combined with thiazide diuretics (Class I, Level A evidence) 1
- Alternatives: ARBs, calcium channel blockers, or thiazide diuretics alone 1
Patients require monthly monitoring until target BP is achieved and optimal therapy is established. 1
Common Pitfalls to Avoid
Do not continue permissive hypertension beyond 72 hours: The rationale for allowing elevated BP (preserving penumbral perfusion) no longer applies after the acute phase. 2, 1
Avoid overly aggressive reduction in intracranial stenosis: Target <140 mmHg systolic, not <130 mmHg, if intracranial atherosclerotic disease is present. 4
Do not delay medication initiation: Start or restart antihypertensives before discharge to reduce recurrence risk. 1
Recognize the U-shaped curve: Both excessively high and excessively low BP are associated with worse outcomes, so avoid hypotension while controlling hypertension. 1