What is the target blood pressure (BP) for a patient with hemorrhagic stroke, considering their history of hypertension?

Target Blood Pressure for Hemorrhagic Stroke

Target systolic blood pressure to 140-160 mmHg within 6 hours of symptom onset for patients with acute intracerebral hemorrhage. 1

Acute Phase Management (First 6 Hours)

The priority is immediate blood pressure reduction to prevent hematoma expansion and improve functional outcomes. 1 The European Society of Cardiology and American Heart Association/American Stroke Association guidelines converge on this target range based on the ATACH-2 and INTERACT2 trials, which demonstrated that more aggressive lowering (targeting 110-139 mmHg) offers no additional benefit and increases adverse events, particularly acute kidney injury. 1

Specific Blood Pressure Targets

• Systolic BP: 140-160 mmHg within 6 hours of onset 1
• Mean arterial pressure: <130 mmHg 1, 2
• Cerebral perfusion pressure: ≥60 mmHg at all times (especially critical if elevated intracranial pressure is present) 1, 2

Critical Safety Parameters to Avoid Harm

Never drop systolic blood pressure by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg. 1, 2 This excessive reduction is associated with:

• Increased mortality 1
• Acute renal injury 1, 2
• Compromised cerebral perfusion 1
• Poor functional recovery 1

The evidence supports a "sweet spot" of 30-45 mmHg reduction over 1 hour, with reductions exceeding 70 mmHg causing harm. 1

Additional Safety Thresholds

• Avoid systolic BP <130 mmHg in patients with large ICH, as this is associated with worse outcomes 1
• Avoid systolic BP <110 mmHg during patient transfer 1
• Never compromise cerebral perfusion pressure below 60 mmHg, even while controlling systemic blood pressure 1, 2

Timing and Monitoring Requirements

Initiate treatment within 2 hours of ICH onset and reach target within 1 hour to reduce hematoma expansion. 1 The therapeutic window for preventing hematoma expansion is narrow, and delaying beyond 6 hours reduces effectiveness. 1

Monitoring Protocol

• Blood pressure every 15 minutes until stabilized 1
• Then every 30-60 minutes for the first 24-48 hours 1
• Neurological assessment using validated scales at baseline and hourly for 24 hours 1
• Continuous assessment for signs of increased intracranial pressure 1

Pharmacological Management

First-line agent: Intravenous labetalol 1, 2

• Dose: 0.3-1.0 mg/kg slow IV every 10 minutes, or
• Continuous infusion: 0.4-1.0 mg/kg/h up to 3 mg/kg/h 1, 2

Alternative: Intravenous nicardipine (preferred by some guidelines for precise titration) 2

• Starting dose: 5 mg/h IV
• Increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h 2

Avoid hydralazine due to unpredictable response and prolonged duration of action, making it less desirable for acute ICH management. 2

Special Considerations for Multicompartmental ICH

For patients with multicompartmental hemorrhage (intraparenchymal plus intraventricular or subarachnoid components), balance systemic blood pressure control with maintenance of adequate cerebral perfusion pressure. 1 Consider accepting slightly higher systemic blood pressure targets if intracranial pressure is significantly elevated. 1 ICP monitoring should be considered in patients with deteriorating neurological status to guide blood pressure management and ensure cerebral perfusion pressure remains adequate. 1

Long-Term Target After Hospital Discharge

Target BP <130/80 mmHg for secondary stroke prevention after the acute phase. 1, 3 This more aggressive long-term target is supported by meta-analyses showing that intensive BP lowering to <130/80 mmHg significantly reduces recurrent stroke risk compared to standard <140/90 mmHg targets, with particular benefit for preventing recurrent intracranial hemorrhage. 3

Common Pitfalls and How to Avoid Them

1. Allowing BP variability: Large fluctuations and peaks in systolic blood pressure worsen functional outcomes independent of mean blood pressure achieved. 1 Use continuous smooth titration rather than intermittent boluses. 1

2. Continuing permissive hypertension beyond 72 hours: The rationale for elevated BP only applies to the acute phase. 1

3. Allowing systolic BP to remain >160 mmHg: This increases hematoma expansion risk. 1

4. Overly aggressive reduction in patients with severe hypertension on presentation: Rapid decline in BP during acute hospitalization is associated with increased death rate. 1, 4