From the Guidelines
For stroke patients, blood pressure management targets depend on the stroke type and phase of care, with the most recent guidelines suggesting that in acute ischemic stroke, blood pressure should initially be maintained below 220/120 mmHg, with more aggressive control to below 185/110 mmHg if thrombolytic therapy (tPA) is planned, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Key Considerations
- In patients not receiving i.v. thrombolysis or mechanical thrombectomy, there is no evidence for 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.
- Patients who are treated with i.v. thrombolysis or mechanical thrombectomy (or both) should have more proactive management of severe hypertension, with BP lowered to <185/110 mmHg prior to thrombolysis and then maintained at <180/105 mmHg over the following 24 h 1.
Blood Pressure Targets
- For patients with acute ischemic stroke and a BP of <180/105 mmHg in the first 72 h after stroke, there is no benefit from the introduction or reintroduction of BP-lowering medication 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.
Medications and Monitoring
- Medications commonly used for blood pressure management in stroke patients include labetalol, nicardipine, ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics 1.
- Blood pressure should be lowered gradually to avoid cerebral hypoperfusion, which could worsen neurological outcomes, with regular monitoring essential, especially in the hyperacute phase 1.
From the Research
Standard Blood Pressure Parameters for Stroke Patients
- The standard blood pressure parameters for stroke patients vary depending on the type of stroke and the stage of treatment 2, 3, 4, 5, 6.
- For patients with acute ischemic stroke, the recommended blood pressure target before starting alteplase (t-PA) is < 185/110 mmHg, and the maintenance blood pressure after tPA administration is < 180/105 mmHg 3, 4, 5.
- For patients with intracerebral hemorrhage (ICH), the evidence from randomized clinical trials supports the immediate blood pressure lowering targeting systolic blood pressure to 140 mmHg 2, 3, 4.
- For patients undergoing mechanical thrombectomy, the optimal blood pressure target is less clear, but guidelines recommend a blood pressure < 185/110 mmHg before thrombectomy, and < 180/105 mmHg during and after thrombectomy 5.
- The American Heart Association/American Stroke Association guidelines recommend values of blood pressure < 185/110 mmHg in patients treated with intravenous t-PA and "permissive hypertension" up to 220/120 mmHg in those not treated with intravenous t-PA 5, 6.
Blood Pressure Targets for Different Stroke Subtypes
- For patients with small vessel or lacunar cerebral ischemia, a reasonable blood pressure lowering target is < 130 mmHg systolic 4.
- For primary stroke prevention, the target blood pressure for those with hypertension is < 140/90 mmHg, and self-measured blood pressure is recommended to assist in blood pressure control 4.
- For recurrent stroke prevention, a blood pressure target of < 130/80 mmHg is suggested 4.
- Blood pressure control is also reasonable for the prevention of cognitive decline or dementia 4.
Considerations for Blood Pressure Management
- Consideration should be given to control of blood pressure variability, especially in the acute phases of stroke, as it may play a role in conferring longer-term outcomes 4.
- The relationship between presenting blood pressure in acute ischemic stroke patients and outcome is complex, with worse outcomes when blood pressure is high or low 5.
- Large, randomized-control studies are needed to make more specific recommendations for blood pressure management in stroke patients 5.