In a patient 15–20 days post spontaneous intracerebral hemorrhage with nighttime blood pressure 146/93 mm Hg and pulse 100 bpm, should antihypertensive therapy be initiated, and which medication is preferred and why?

Blood Pressure Management 15-20 Days Post-ICH

Yes, initiate antihypertensive therapy now—your patient's BP of 146/93 mmHg warrants treatment to prevent recurrent stroke, and the subacute phase (15-20 days post-ICH) is the appropriate time to begin long-term secondary prevention with combination therapy using an ACE inhibitor plus diuretic. 1

Why Treatment is Indicated Now

Your patient is well beyond the acute phase (first 6 hours) and is now in the secondary prevention window where blood pressure control dramatically reduces recurrent stroke risk:

• The PROGRESS trial demonstrated a 50% relative risk reduction in recurrent ICH (from 2% to 1% absolute risk) and a 49% reduction in any recurrent stroke when patients post-ICH received blood pressure-lowering therapy 1
• This benefit applied regardless of whether patients were hypertensive or normotensive after their initial stroke 1
• PROGRESS enrolled patients up to 5 years after stroke onset, and there was no difference in treatment effect based on timing from stroke—meaning your patient at 15-20 days is well within the therapeutic window 1

Target Blood Pressure for Secondary Prevention

Your target should be <130/80 mmHg for long-term secondary stroke prevention after hospital discharge 2

• Current BP of 146/93 mmHg exceeds this target and requires intervention
• The systolic of 146 mmHg is above the recommended threshold
• The diastolic of 93 mmHg also exceeds the 80 mmHg target

Recommended Medication Regimen

Start perindopril 4 mg daily plus indapamide 2.5 mg daily 1

This specific combination is recommended because:

• This exact regimen was used in the PROGRESS trial that demonstrated the 50% reduction in recurrent ICH 1
• The combination of ACE inhibitor plus diuretic provides superior stroke prevention compared to monotherapy 1
• No other antihypertensive drug classes have RCT evidence specifically in post-ICH patients 1

Addressing Your Nighttime Concerns

Your concern about BP rising at night is valid, but do not use short-acting agents or attempt acute BP lowering at this stage:

• You are 15-20 days post-stroke—the critical window for preventing hematoma expansion (first 6 hours) has long passed 2
• Acute intensive BP lowering targets (140-160 mmHg within 1 hour) apply only to the hyperacute phase, not to your patient's current subacute presentation 2
• Starting long-acting agents (perindopril + indapamide) tonight will provide gradual, sustained BP control over days—this is the appropriate approach for secondary prevention 1
• Rapid BP fluctuations and variability worsen outcomes—smooth, gradual control is safer than aggressive nighttime intervention 2

Why Not Use Acute-Phase Agents

Do not use IV nicardipine, IV labetalol, or other acute agents at this stage:

• These are reserved for hyperacute ICH (first 6 hours) when preventing hematoma expansion is the goal 2, 3
• Your patient's BP of 146/93 mmHg does not constitute a hypertensive emergency requiring immediate IV therapy 1
• Patients with substantially elevated BP who lack acute target organ damage should be treated with oral antihypertensive therapy, not IV agents 1

Practical Implementation

Start tonight with oral perindopril 4 mg + indapamide 2.5 mg as a single daily dose:

• These are long-acting agents that can be given once daily, typically in the morning
• Monitor BP daily and adjust as needed to reach target <130/80 mmHg over the next 1-2 weeks
• The pulse rate of 100 bpm may reflect inadequate BP control and should improve with treatment
• Ensure adherence—nonadherence is frequently reported in post-stroke patients and relates to support from caregivers and healthcare professionals 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for "perfect" timing—the evidence shows benefit regardless of when treatment starts post-stroke 1
• Do not use monotherapy—the PROGRESS trial showed the combination was superior 1
• Do not target acute-phase BP goals (140-160 mmHg)—your patient needs long-term secondary prevention targets (<130/80 mmHg) 2
• Do not use agents without evidence in ICH—stick with the proven perindopril + indapamide combination 1

Monitoring Requirements

• Check BP daily initially, then weekly once stable
• Monitor renal function and electrolytes within 1-2 weeks of starting therapy (ACE inhibitor and diuretic effects)
• Assess for orthostatic hypotension, especially given the pulse rate of 100 bpm
• Reinforce adherence at every visit—this is critical for maintaining the 50% risk reduction benefit 1