From the Guidelines
Duration of Permissive Hypertension in Acute Ischemic Stroke or TIA
Permissive hypertension in acute ischemic stroke or Transient Ischemic Attack (TIA) is generally allowed for a period of 24 to 72 hours [ 1 ], with blood pressure thresholds not to exceed 220/120 mmHg.
- The primary goal during this period is to avoid actively lowering blood pressure unless it is extremely high, as cerebral autoregulation may be impaired in acute stroke, and maintaining cerebral perfusion relies on systemic BP [ 1 ].
- In patients undergoing treatment with i.v. thrombolysis or mechanical thrombectomy, blood pressure should be lowered to <185/110 mmHg prior to treatment and maintained at <180/105 mmHg over the following 24 hours [ 1 ].
- For patients not receiving these treatments, there is no evidence for actively lowering BP unless it is extremely high, and an initial moderate relative reduction of 10%–15% over a period of hours may be considered [ 1 ].
- Patients with acute ischemic stroke and a BP of <180/105 mmHg in the first 72 hours after stroke do not seem to benefit from the introduction or reintroduction of BP-lowering medication [ 1 ].
- However, 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 ].
From the Research
Duration of Permissive Hypertension
The duration of permissive hypertension in acute ischemic stroke or Transient Ischemic Attack (TIA) is generally considered to be within the first 24 hours after onset of stroke.
- Permissive hypertension is recommended for patients with systolic blood pressure greater than 220 mm Hg or diastolic blood pressure greater than 120 mm Hg 2, 3, 4, 5.
- For patients undergoing intravenous thrombolysis for acute ischemic stroke, it is recommended that the blood pressure be reduced and maintained below 185 mm Hg systolic for the first 24 hours 2, 3.
- The goal of permissive hypertension is to avoid lowering blood pressure too quickly, which can worsen outcomes, and to allow for spontaneous decline in blood pressure over time 5.
- The optimal duration of permissive hypertension may vary depending on individual patient factors and comorbid conditions, such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia 2.
Blood Pressure Targets
The blood pressure targets for permissive hypertension in acute ischemic stroke or TIA are:
- Systolic blood pressure greater than 220 mm Hg or diastolic blood pressure greater than 120 mm Hg 2, 3, 4, 5
- Systolic blood pressure below 185 mm Hg for patients undergoing intravenous thrombolysis 2, 3
- Systolic blood pressure below 180 mm Hg to limit the risk of intracerebral hemorrhage (ICH) 3
- Systolic blood pressure below 140 mm Hg for patients with acute intra-cerebral hemorrhage 3, 4