Blood Pressure Management After Stroke: Target <130/80 mmHg, Not Permissive Hypertension
For Chinese patients with a history of stroke taking aspirin, target a blood pressure of <130/80 mmHg rather than permissive hypertension, as this approach reduces cardiovascular outcomes and recurrent stroke risk. 1
Primary Blood Pressure Target
The most recent 2024 European Society of Cardiology guidelines recommend targeting systolic blood pressure to 120-130 mmHg specifically for patients with ischemic stroke or TIA when treatment is tolerated. 1
The 2017 ACC/AHA guidelines support a blood pressure goal of <130/80 mmHg for adults who have experienced stroke or TIA, with this being a Class IIb recommendation (may be reasonable). 1
The World Stroke Organization's 2023 systematic review confirms that the target blood pressure for patients with stroke or TIA is <130/80 mmHg across all resource settings. 1
Why Not Permissive Hypertension?
Permissive hypertension is only appropriate in the acute stroke phase (first 48-72 hours) and only for specific situations: patients treated with thrombolytics, or those with systolic BP >220 mmHg or diastolic BP >120 mmHg. 1
For all other acute ischemic stroke patients, restarting antihypertensive therapy after the first 24-48 hours to improve long-term BP control is reasonable for patients who are neurologically stable. 1
Post hoc analysis of the WASID trial demonstrated that patients with intracranial stenosis had fewer strokes and other vascular events (HR 0.59) when long-term BP was maintained <140/90 mmHg. 1
CAST Study Context
The CAST trial enrolled 21,106 Chinese patients with acute ischemic stroke and focused on aspirin 160 mg daily versus placebo, not blood pressure targets. 2
CAST demonstrated aspirin's benefit in reducing recurrent ischemic stroke by 14% and mortality, but did not establish permissive hypertension as a treatment strategy. 2, 3
The combined CAST and IST analysis of 40,000 patients showed aspirin reduces recurrent stroke by 7 per 1000 patients, but this benefit is independent of blood pressure management strategy. 3
Medication Selection Algorithm
First-line agents should include thiazide diuretics, ACE inhibitors, or ARBs, with combination therapy of thiazide diuretic plus ACE inhibitor being particularly effective. 1
For Chinese patients specifically, initial antihypertensive treatment can include any of these classes, though combination therapy is often required to achieve target BP. 1
Beta-blockers should be reserved for patients with specific indications such as ischemic heart disease, myocardial infarction history, or heart failure. 1
Timing of Blood Pressure Lowering
Avoid aggressive BP lowering in the first 48-72 hours after acute ischemic stroke unless BP exceeds 220/120 mmHg, as cerebral autoregulation is impaired and systemic perfusion pressure is needed for the ischemic penumbra. 1
Blood pressure treatment should be initiated or restarted as soon as possible after the acute phase, ideally before hospital discharge. 1
For patients with BP >140/90 mmHg who are neurologically stable, restarting antihypertensive treatment after the first few days is safe and improves long-term BP control. 1
Critical Pitfalls to Avoid
Do not maintain permissive hypertension beyond the acute stroke phase (48-72 hours), as chronic hypertension significantly increases recurrent stroke risk. 1
Avoid rapid BP reduction even within the hypertensive range during acute stroke, as this can be detrimental to cerebral perfusion in the ischemic penumbra. 1
Do not assume that because CAST was a Chinese trial studying aspirin, it endorses permissive hypertension—the trial did not address BP targets. 2
Ensure aspirin dosing remains in the 81-325 mg daily range as recommended by guidelines, with the CAST dose of 160 mg being within this therapeutic window. 1, 2