When can routine antihypertensive therapy be restarted in a hypertensive patient who suffered a cerebrovascular accident yesterday at 3 PM and now has a blood pressure of 160/90 mm Hg?

When to Restart Antihypertensives After Acute Ischemic Stroke

You should restart routine antihypertensive medications now (approximately 24 hours post-stroke) in this neurologically stable patient with a BP of 160/90 mmHg.

Evidence-Based Timing for Restarting Antihypertensives

After 24 hours, restarting antihypertensive therapy is reasonable for patients with preexisting hypertension who are neurologically stable, as this approach improves long-term BP control without compromising acute outcomes. 1

• The 2017 ACC/AHA guidelines provide a Class IIa recommendation (reasonable and safe) for starting or restarting antihypertensive therapy during hospitalization in patients with BP >140/90 mmHg who are neurologically stable. 1

• The critical window is after the first 24 hours for patients with preexisting hypertension who remain neurologically stable, unless a specific contraindication exists. 1

Why 24 Hours Is the Key Threshold

• The permissive hypertension period (avoiding treatment) applies primarily to the first 48-72 hours, but this recommendation is strongest for patients who have not received thrombolysis and whose BP remains <220/120 mmHg. 1, 2

• For patients with preexisting hypertension (like yours), the evidence supports earlier resumption at 24 hours rather than waiting the full 48-72 hours, provided neurological stability is confirmed. 1, 2

• Your patient's BP of 160/90 mmHg is well below the 220/120 mmHg threshold that would mandate treatment avoidance during the acute phase. 1

Critical Distinction: Did This Patient Receive Thrombolysis?

If Thrombolysis Was Given:

• BP must be maintained <180/105 mmHg for at least 24 hours after rtPA to minimize hemorrhagic transformation risk. 1
• At 24 hours post-thrombolysis, you can now restart home antihypertensives to maintain this target. 1

If No Thrombolysis Was Given:

• The Class III (No Benefit) recommendation against treating BP <220/120 mmHg applies most strongly to the first 48-72 hours. 1, 2
• However, for patients with preexisting hypertension, restarting medications after 24 hours is explicitly supported as reasonable. 1, 2

Physiologic Rationale

• Cerebral autoregulation is impaired in the ischemic penumbra during the acute phase, making cerebral blood flow dependent on systemic perfusion pressure. 1, 2

• The U-shaped relationship between BP and outcomes shows optimal systolic BP of 121-200 mmHg in the acute phase. 1, 2

• After 24 hours, the risk of extending the infarct through BP reduction diminishes, while the benefits of long-term BP control for secondary prevention become more relevant. 2, 3

Practical Implementation

Restart the patient's home antihypertensive regimen now, targeting a BP <140/90 mmHg initially, with a long-term goal of <130/80 mmHg for secondary stroke prevention. 1, 2

• Preferred agents for long-term secondary prevention include thiazide diuretics, ACE inhibitors, ARBs, or combination therapy (thiazide plus ACE inhibitor). 1

• Avoid rapid or aggressive BP reduction; gradual titration over days to weeks is appropriate. 2, 4

Common Pitfalls to Avoid

• Do not automatically withhold antihypertensives for the full 48-72 hours in patients with preexisting hypertension who are neurologically stable at 24 hours—this represents overly conservative management. 1, 2

• Confirm neurological stability before restarting medications; any ongoing deterioration mandates holding antihypertensives regardless of timing. 1, 2

• Avoid sublingual nifedipine or other agents causing precipitous BP drops that cannot be titrated. 2, 4

• Recognize exceptions requiring immediate BP control regardless of stroke timing: hypertensive encephalopathy, acute MI, acute pulmonary edema, aortic dissection, or acute renal failure. 2, 4

Strength of Evidence

• The recommendation to restart antihypertensives after 24 hours in patients with preexisting hypertension is supported by Class IIa evidence from the ACC/AHA guidelines. 1, 2

• One RCT showed no benefit to continuing prestroke antihypertensives during the first few days, but it was substantially underpowered. 1

• A recent 2023 multicenter RCT (4,810 patients) found that early antihypertensive treatment (within 24-48 hours) did not reduce dependency or death at 90 days compared to delayed treatment, but this study excluded patients receiving thrombolysis and focused on patients with BP 140-220 mmHg. 5

• The evidence consistently shows that initiating or reinitiating treatment within 48-72 hours in patients with BP <220/120 mmHg who did not receive thrombolysis is ineffective (Class III), but this does not preclude restarting medications after 24 hours in patients with preexisting hypertension who are stable. 1