What is the target blood pressure (BP) for a patient with acute ischemic stroke within the first week?

Target Blood Pressure in Acute Ischemic Stroke Within the First Week

For patients with acute ischemic stroke, maintain permissive hypertension (avoid treating BP unless >220/120 mmHg) during the first 48-72 hours, then transition to a target of <140/90 mmHg starting on day 3-4 for neurologically stable patients. 1, 2

Days 0-3: Acute Phase Management

For Patients NOT Receiving Reperfusion Therapy

• Avoid treating BP unless systolic >220 mmHg or diastolic >120 mmHg during the first 48-72 hours. 3, 1, 4
• If BP exceeds 220/120 mmHg, reduce mean arterial pressure by only 15% over the first 24 hours—not more aggressively. 3, 1, 4
• The rationale: cerebral autoregulation is impaired in the ischemic penumbra, and systemic perfusion pressure is needed for blood flow to potentially salvageable brain tissue. 1, 4
• Rapid or aggressive BP reduction can extend infarct size by reducing perfusion to the penumbra and cause neurological worsening. 3, 4

For Patients Receiving IV Thrombolysis (rtPA)

• Lower BP to <185/110 mmHg BEFORE initiating rtPA. 3, 1, 4
• Maintain BP <180/105 mmHg for at least 24 hours after thrombolysis. 3, 1, 4
• Monitor BP every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly for 16 hours. 3, 4
• High BP during the initial 24 hours after thrombolysis significantly increases risk of symptomatic intracranial hemorrhage. 4, 5
• Recent evidence suggests that attaining SBP 110-140 mmHg consistently over 24 hours is associated with better outcomes in thrombolyzed patients. 5

For Patients Receiving Mechanical Thrombectomy

• Maintain BP <185/110 mmHg before the procedure. 4
• Maintain systolic BP <180 mmHg after the procedure for at least 24 hours. 4
• Periinterventional SBP between 140-160 mmHg appears favorable, as decreases from baseline BP during intervention are detrimental. 6

Preferred Antihypertensive Agents for Acute Phase

• Labetalol: 10-20 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg), or continuous infusion at 2-8 mg/min. 3, 4
• Nicardipine: 5 mg/h IV infusion, titrate by 2.5 mg/h every 5-15 minutes to maximum 15 mg/h. 3, 4
• Avoid sublingual nifedipine (cannot be titrated, causes precipitous drops). 4
• Avoid sodium nitroprusside except for refractory hypertension (adverse effects on cerebral autoregulation and intracranial pressure). 4

Days 3-7: Transition to Secondary Prevention

Target BP After Day 3

• For neurologically stable patients with BP ≥140/90 mmHg after 3 days, initiate or reintroduce antihypertensive medications with a target of <140/90 mmHg. 1, 2
• By day 5, permissive hypertension is no longer appropriate—the acute phase guidelines only apply to the first 48-72 hours. 2
• After 3 days, the risk of cerebral hypoperfusion decreases while benefits of BP control for secondary prevention become more relevant. 1

Medication Selection for Long-Term Management

• Preferred regimens: ACE inhibitors combined with thiazide diuretics (Class I, Level A evidence). 2
• Alternative agents include ARBs or thiazide diuretics alone. 1, 2
• Start or restart antihypertensives before hospital discharge to reduce recurrence risk. 2
• Patients require monthly monitoring until target BP is achieved. 2

Special Populations

• For diabetic patients: target <130/80 mmHg. 2
• For patients with intracranial atherosclerotic disease: target <140 mmHg systolic (not <130 mmHg). 2
• Some evidence suggests <130/80 mmHg may be reasonable for secondary prevention, particularly in lacunar stroke. 1

Critical Pitfalls to Avoid

• Do not continue permissive hypertension beyond 72 hours—the rationale for allowing elevated BP no longer applies after the acute phase. 2
• Avoid excessive BP reduction (>70 mmHg drop or >15% reduction in MAP) in the acute phase—this may cause acute renal injury, neurological deterioration, and extend infarct size. 3, 1, 4
• Do not initiate antihypertensive therapy too early (before 3 days) in patients with BP <220/120 mmHg who did not receive reperfusion therapy—this has been shown ineffective for preventing death or dependency. 1
• Both excessively high and excessively low BP are associated with worse outcomes—a U-shaped relationship exists with optimal admission systolic BP ranging from 121-200 mmHg. 4, 7
• Do not delay medication initiation after day 3—start before discharge to establish optimal therapy. 2

Override Situations Requiring Immediate BP Control

Regardless of stroke guidelines, treat BP immediately in these conditions: 4

• Hypertensive encephalopathy
• Aortic dissection
• Acute myocardial infarction
• Acute pulmonary edema
• Acute renal failure