What are the recommended systolic blood pressure targets for a patient with acute intracerebral hemorrhage on day 1 (first 24 hours) and from day 2 onward?

Blood Pressure Targets in Acute Intracerebral Hemorrhage

For patients with acute intracerebral hemorrhage presenting with systolic blood pressure 150–220 mmHg, target a systolic BP of 140 mmHg (acceptable range 130–150 mmHg) within 1 hour of treatment initiation and maintain this target continuously for at least 7 days—this applies equally to day 1 and day 2 onward. 1, 2

Day 1 (First 24 Hours): Aggressive Early Control

Primary Target and Timing

• Initiate antihypertensive therapy within 2 hours of symptom onset to maximize reduction in hematoma expansion 1, 2
• Achieve systolic BP of 140 mmHg (range 130–150 mmHg) within 1 hour of starting treatment 1, 2
• This aggressive early approach is supported by the 2022 American Heart Association/American Stroke Association guidelines (Class I, Level A recommendation) 1, 2

Critical Safety Boundaries on Day 1

• Never lower systolic BP below 130 mmHg—this carries a Class III: Harm recommendation and is associated with worse neurological outcomes and increased mortality 1, 2
• Avoid dropping systolic BP by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg, as this increases risk of acute kidney injury and neurological deterioration 1, 3
• Maintain cerebral perfusion pressure ≥60 mmHg at all times, especially if intracranial pressure is elevated 1, 2

Preferred Pharmacologic Agent

• Intravenous nicardipine is the first-line agent: start at 5 mg/hour and titrate by 2.5 mg/hour every 5 minutes up to a maximum of 15 mg/hour 1
• Nicardipine allows precise titration and sustained BP control, which is critical for minimizing blood pressure variability 1
• Labetalol is an acceptable alternative when nicardipine is unavailable or contraindicated 1

Monitoring Intensity on Day 1

• Measure BP every 15 minutes until target is reached, then every 30–60 minutes for the first 24 hours 1
• Use continuous arterial line monitoring for patients on continuous IV antihypertensives 2
• Minimize BP variability—large fluctuations in systolic BP independently worsen functional outcomes, even when mean BP is within target 1, 4

Day 2 Onward (Through Day 7): Sustained Control

Unchanged Target Range

• Continue targeting systolic BP 130–150 mmHg for at least 7 days after ICH onset 1, 2
• The target does NOT change after day 1—the same 140 mmHg goal (range 130–150 mmHg) applies throughout the acute hospitalization 1, 2

Rationale for Sustained Control

• The therapeutic window extends beyond the first 24 hours; smooth, sustained BP control through day 7 limits variability-related harm and prevents delayed hematoma expansion 1, 2
• High BP variability during the first 24–48 hours is independently associated with death and severe disability at 90 days 1, 4

Transition Strategy

• Continue continuous IV infusion (nicardipine or labetalol) as long as needed to maintain smooth control without peaks 1
• Transition to oral antihypertensives only when BP is stable and variability is minimized 2
• Avoid intermittent boluses, which increase BP variability 5

Special Populations and Caveats

Patients with Initial Systolic BP ≥220 mmHg

• Exercise extreme caution: intensive BP lowering in this subgroup is associated with higher rates of neurological deterioration (15.5% vs 6.8%) and acute kidney injury without benefit in reducing death or severe disability 3
• In these patients, do not drop systolic BP by more than 70 mmHg in the first hour 1, 3

Large or Surgically Decompressed ICH

• The safety and efficacy of intensive BP lowering are uncertain in patients with large hematomas or those requiring surgical decompression 1, 2
• In these cases, accept slightly higher systemic BP targets (e.g., 150–160 mmHg) if intracranial pressure is markedly elevated, provided cerebral perfusion pressure remains ≥60 mmHg 1, 5

Patients with Glasgow Coma Scale <5

• Evidence for intensive BP lowering is limited in patients with severe ICH (GCS <5), as they were largely excluded from INTERACT2 and ATACH-2 trials 2

Common Pitfalls to Avoid

• Delaying treatment beyond 2 hours from symptom onset markedly narrows the therapeutic window 1, 2
• Allowing BP to drift above 160 mmHg increases risk of hematoma expansion 1
• Lowering BP below 130 mmHg is harmful and associated with worse outcomes 1, 2, 4
• Permitting large BP variability (peaks and fluctuations) worsens functional outcomes independent of mean BP achieved 1, 4
• Using glyceryl trinitrate (GTN) should be avoided, as the RIGHT-2 trial showed it was associated with greater hematoma growth and poorer outcomes 1

Contrast with Older Guidelines

The 2010 AHA/ASA guidelines suggested a more conservative approach, with a systolic BP target of <180 mmHg for patients presenting with systolic BP 150–220 mmHg 6. However, the 2022 guidelines represent a paradigm shift based on INTERACT2 and ATACH-2 trial data, establishing 140 mmHg (range 130–150 mmHg) as the optimal target with Class I, Level A evidence 1, 2. The older, more permissive target of <180 mmHg is no longer recommended for patients in the 150–220 mmHg range 6, 1.