What are the guidelines for permissive hypertension in acute ischemic stroke?

From the Guidelines

Permissive hypertension is generally allowed in acute ischemic stroke, with no active lowering of blood pressure unless it is extremely high (e.g., >220/120 mmHg) or in patients receiving intravenous thrombolysis or mechanical thrombectomy 1.

Guidelines for Blood Pressure Management

• In patients not receiving i.v. thrombolysis or mechanical thrombectomy, no evidence supports actively lowering BP unless it is extremely high (e.g., >220/120 mmHg) 1.
• If BP is extremely high, an initial moderate relative reduction of 10%–15% over a period of hours may be considered 1.
• In patients undergoing treatment with i.v. thrombolysis, BP should be lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1.
• In patients undergoing treatment with mechanical thrombectomy (with or without i.v. thrombolysis), BP should also be lowered to <180/105 mmHg prior to thrombectomy and maintained over the next 24 h 1.
• For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischemic stroke, initiation or reintroduction of BP-lowering medication is recommended 1.

Rationale for Permissive Hypertension

• Cerebral autoregulation may be impaired in acute stroke, and maintaining cerebral perfusion relies on systemic BP 1.
• Rapid reduction of BP can be detrimental, especially in patients with impaired cerebral autoregulation 1.
• The optimal blood pressure range during acute ischemic stroke likely depends on the stroke subtype and other patient-specific comorbidities 1.

Medications for Blood Pressure Management

• Labetalol 10–20 mg IV over 1–2 minutes, may repeat 1 time; or Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h, may be used to manage BP in patients receiving intravenous thrombolysis or mechanical thrombectomy 1.

From the Research

Guidelines for Permissive Hypertension in Acute Ischemic Stroke

• The management of blood pressure in acute ischemic stroke is a topic of controversy, with some studies suggesting that permissive hypertension may be beneficial in the early stages of stroke 2, 3.
• Current guidelines recommend that blood pressure be maintained below 185/110 mmHg in patients who are candidates for intravenous tissue plasminogen activator (IV tPA) or mechanical thrombectomy, and below 180/105 mmHg for at least 24 hours in patients who have received IV tPA or have undergone mechanical thrombectomy 4.
• For patients with marked elevation in blood pressure, a reasonable goal would be to lower blood pressure by 15% during the first 24 hours after onset of stroke, with medications withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 3.
• The first-line drugs for lowering of blood pressure remain labetalol, nicardipine, and sodium nitroprusside, although the choice of treatment should be adjusted to different clinical and blood pressure parameters 5, 3.

Blood Pressure Management in Acute Ischemic Stroke

• Elevated blood pressure in acute ischemic stroke is common, and a raised blood pressure is related to mortality and disability, yet excessive blood pressure lowering can be detrimental 5.
• Permissive hypertension is recommended during the first 24 hours after stroke onset, although there is ongoing uncertainty regarding the most appropriate blood pressure management in the acute phase of ischemic stroke 5, 6.
• The optimal blood pressure management in acute ischemic stroke remains insufficient and relies on expert consensus statements, with a need for further research to determine the best approach to blood pressure management in this setting 2, 4.

Special Considerations

• Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia would override the guidelines for permissive hypertension, with a lower blood pressure preferred in these conditions 3.
• Children with acute strokes should be managed in the same way as adults, with extrapolated lowering of blood pressures, until further evidence emerges 3.