What is the long-term blood pressure (BP) goal for patients following an ischemic stroke?

Long-Term Blood Pressure Goal Following Ischemic Stroke

For patients who have experienced an ischemic stroke or TIA, the long-term blood pressure goal should be <130/80 mmHg, initiated after the first few days of the acute event once neurological stability is achieved. 1

Primary Target and Strength of Recommendation

• The 2021 AHA/ASA Stroke Prevention Guidelines provide a Class I, Level B-R recommendation for a BP goal of <130/80 mmHg in patients with hypertension following stroke or TIA. 1
• This represents the most recent and highest-quality guideline recommendation, superseding the earlier 2017 ACC/AHA guidelines which listed this target as Class IIb (may be reasonable). 1
• Meta-analyses demonstrate that intensive BP lowering to <130/80 mmHg significantly reduces recurrent stroke risk compared to standard targets of <140/90 mmHg, with particular benefit in reducing intracranial hemorrhage. 2

Timing of Initiation

• Antihypertensive therapy should be restarted or initiated after the first few days (typically 3+ days) of the index stroke event in neurologically stable patients with BP ≥140/90 mmHg. 1
• Do NOT aggressively lower BP during the acute phase (first 48-72 hours) unless BP exceeds 220/120 mmHg, as permissive hypertension may enhance collateral flow to ischemic tissue. 1
• Starting or restarting antihypertensive therapy during hospitalization in neurologically stable patients with BP >140/90 mmHg is safe and reasonable for improving long-term BP control. 1

Preferred Antihypertensive Agents

The following medication classes have Class I, Level A evidence for secondary stroke prevention: 1

• Thiazide diuretics (reduce recurrent stroke risk by approximately 30%) 1
• ACE inhibitors (proven benefit in RCTs) 1
• Angiotensin receptor blockers (ARBs) (proven benefit in RCTs) 1
• Combination therapy with thiazide diuretic plus ACE inhibitor (particularly effective) 1

Special Considerations and Target Modifications

For Lacunar (Small Vessel) Stroke

• A target systolic BP <130 mmHg may be reasonable, with some evidence suggesting benefit from even more intensive control. 1

For Intracranial Large Artery Atherosclerosis

• A higher BP target (closer to <140/90 mmHg) may be appropriate, as excessive BP lowering could compromise cerebral perfusion in patients with severe stenosis. 1, 2
• Use a stepped-care approach with cautious BP lowering to <140/90 mmHg for patients with severe diseases of major cerebral vessels. 2

For Patients at High Risk of Hemorrhagic Stroke

• More aggressive BP lowering (toward <120/80 mmHg) may provide additional benefit in reducing intracranial hemorrhage risk. 2, 3

Critical Pitfalls to Avoid

• Do not lower BP too aggressively in the acute phase (first 48-72 hours), as cerebral autoregulation is impaired and systemic perfusion pressure is needed for oxygen delivery to the ischemic penumbra. 1, 4
• Avoid diastolic BP <60 mmHg, as this increases risk of adverse outcomes. 5
• Monitor for orthostatic hypotension, particularly in elderly patients, as this increases fall risk. 5
• Recognize the U-shaped relationship between BP and outcomes—both excessively high and low BP are associated with worse prognosis. 6, 2

Monitoring Strategy

• Patients require frequent monitoring (monthly) until target BP is achieved and optimal therapy is established. 6
• Once stable, continue regular monitoring to maintain BP control and prevent recurrent stroke. 1

Algorithm for Decision-Making

1. Days 0-3 post-stroke: Maintain permissive hypertension unless BP >220/120 mmHg or patient received thrombolysis 1
2. After day 3 in neurologically stable patients:
   • If BP ≥140/90 mmHg → Initiate/restart antihypertensives 1
   • Standard target: <130/80 mmHg 1
   • If lacunar stroke → Consider <130 mmHg systolic 1
   • If severe intracranial stenosis → Consider <140/90 mmHg 1, 2
   • If high hemorrhagic risk → Consider more intensive control toward <120/80 mmHg 2
3. First-line agents: Thiazide diuretic, ACE inhibitor, ARB, or combination therapy 1
4. Monitor monthly until target achieved, then regularly thereafter 6