In an adult with acute hemorrhagic stroke, what is the target diastolic blood pressure and recommended intravenous antihypertensive management to achieve it?

Target Diastolic Blood Pressure in Acute Hemorrhagic Stroke

For acute intracerebral hemorrhage (ICH) with systolic BP 150-220 mmHg presenting within 6 hours, do not aggressively lower blood pressure to achieve a diastolic target <90 mmHg (corresponding to systolic <140 mmHg), as this approach provides no benefit in reducing death or severe disability and increases the risk of renal complications. 1

Blood Pressure Management Algorithm for Hemorrhagic Stroke

For SBP 150-220 mmHg (presenting within 6 hours):

• Avoid intensive lowering to SBP <140 mmHg (which would correspond to DBP typically <90 mmHg), as the most recent high-quality RCT found this target did not reduce death or disability compared to standard reduction (SBP 140-179 mmHg) and caused significantly more renal adverse events within 7 days. 1

• The 2017 ACC/AHA guidelines assign a Class III: Harm recommendation to immediate lowering of SBP to <140 mmHg in this population, indicating it may be potentially harmful. 1

• Standard approach: Target SBP 140-179 mmHg (corresponding to DBP approximately 90-110 mmHg), which represents the safer comparator arm in recent trials. 1

For SBP >220 mmHg:

• Use continuous IV infusion with close BP monitoring to lower systolic blood pressure, as markedly elevated BP is associated with greater hematoma expansion, neurological worsening, and death. 1, 2

• While specific diastolic targets are not explicitly defined for this range, the focus remains on systolic reduction using titratable IV agents. 1, 2

Recommended IV Antihypertensive Agents

First-line options:

• Labetalol: 10-20 mg IV over 1-2 minutes, may repeat; or continuous infusion 2-8 mg/min. Preferred due to ease of titration and minimal cerebral vasodilatory effects. 3, 4

• Nicardipine: 5 mg/h IV, titrate by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h. Effective alternative, especially useful with bradycardia or heart failure. 3, 4

Agents to avoid:

• Sodium nitroprusside: Avoid due to adverse effects on cerebral autoregulation and intracranial pressure; reserve only for refractory hypertension. 3

• Sublingual nifedipine: Cannot be titrated and causes precipitous BP drops. 3

Evidence Synthesis and Nuances

The evidence for hemorrhagic stroke BP management has evolved significantly. Earlier trials (INTERACT-1, ATACH) suggested that rapid BP lowering to SBP <140 mmHg was feasible and safe, with possible attenuation of hematoma growth. 1 However, the most recent and definitive trial (ATACH-2, referenced in the 2017 ACC/AHA guidelines) examined immediate BP lowering within 4.5 hours and found that intensive treatment (SBP 110-139 mmHg) did not improve outcomes compared to standard treatment (SBP 140-179 mmHg). 1

Critical distinction from ischemic stroke:

Unlike ischemic stroke where diastolic targets are explicitly stated for thrombolysis candidates (DBP <110 mmHg before, <105 mmHg after), hemorrhagic stroke guidelines focus primarily on systolic targets because there is no perihematomal penumbra requiring perfusion pressure maintenance. 1, 5

Common Pitfalls to Avoid

• Over-aggressive lowering: Targeting SBP <140 mmHg (and corresponding lower diastolic pressures) increases renal complications without improving neurological outcomes. 1

• Delayed treatment of severe hypertension: For SBP >220 mmHg, failure to initiate continuous IV infusion with close monitoring may allow continued hematoma expansion. 1, 2

• Using non-titratable agents: Sublingual medications cannot be adjusted if BP drops too rapidly. 3

Monitoring Requirements

• Frequent BP checks are essential during IV infusion to avoid excessive drops that could compromise cerebral perfusion or cause acute kidney injury. 1, 4

• Monitor renal function closely, as intensive BP lowering has been associated with increased renal adverse events. 1