What are the optimal blood pressure parameters after a cerebrovascular accident (CVA) or stroke?

From the Guidelines

Blood pressure management after stroke should aim for a target of consistently lower than 140/90 mmHg, with more aggressive control for patients with diabetes or small subcortical stroke, targeting systolic blood pressure consistently lower than 130 mmHg 1.

Key Considerations

• For patients who have had a stroke or transient ischemic attack, blood pressure lowering treatment is recommended to achieve a target of consistently lower than 140/90 mmHg 1.
• In the acute phase (first 24-48 hours), permissive hypertension up to 220/120 mmHg may be allowed unless thrombolysis is planned, in which case BP should be <180/105 mmHg 1.
• For patients with diabetes, blood pressure lowering treatment is recommended to attain systolic blood pressure targets consistently lower than 130 mmHg and diastolic blood pressure targets consistently lower than 80 mmHg 1.
• Blood pressure should be lowered gradually, avoiding drops exceeding 15% in the first 24 hours to prevent hypoperfusion of the penumbra area.

Management Approach

• First-line medications for acute blood pressure management include labetalol, nicardipine, or clevidipine.
• Long-term management typically involves ACE inhibitors like ramipril or perindopril, often combined with thiazide diuretics.
• Patients who are not started on hypertensive therapy in acute care should have arrangements made for follow-up with primary care or stroke prevention service for ongoing evaluation and management 1.

Special Considerations

• In patients with nondiabetic chronic kidney disease and stroke, blood pressure lowering treatment is recommended to attain a blood pressure consistently lower than 140/90 mmHg 1.
• For children, blood pressure lowering should be targeted to below the 95th percentile on normative value tables for age, height, and gender 1.
• Blood pressure management is the responsibility of all health care team members, and initially stroke patients require frequent monitoring (e.g. monthly) until they achieve target blood pressure levels and optimal therapy has been established 1.

From the Research

Blood Pressure Parameters After Stroke

• The optimal blood pressure (BP) management is essential for the prevention of recurrent stroke, with a target BP of <130/80 mmHg established by clinical practice guidelines 2.
• However, the target BP needs to be individualized, with a stepped-care approach for cautious BP lowering (usually to levels <140/90 mmHg) preferred for patients with severe diseases of the major cerebral vessels, who have a high risk of recurrent ischemic stroke 2.
• More aggressive BP lowering (to levels <120/80 mmHg) tends to benefit patients at high risk of intracranial hemorrhage 2.
• In patients with previous transient ischemic attack or chronic stroke, blood pressure reduction appears to be a safe and important facet of the secondary prevention of recurrent stroke 3.
• The management of blood pressure in acute stroke is complicated by the effect blood pressure changes may have on cerebral perfusion, with current protocols requiring strict blood pressure control in patients who are treated with thrombolytic therapy, to reduce the risk of hemorrhagic complications 3.

Blood Pressure Monitoring

• Twenty-four hour ambulatory BP monitoring (ABPM) has become an important tool for improving the diagnosis and management of hypertension, and is increasingly used to assess patients with hypertension 4.
• ABPM has demonstrated chronic disruption of the circadian rhythm of BP after acute phase of stroke and has shown higher sensitivity compared to office BP in evaluating the effectiveness of antihypertensive treatment among stroke survivors 4.
• High 24-hour BP is an independent predictor for cerebrovascular events, brain microbleeds, and subsequent development of dementia 4.

Management of Blood Pressure in Stroke

• The key BP target before starting alteplase (t-PA) is <185/110 mm Hg, and the maintenance BP after tPA administration is <180/105 mm Hg 5.
• For IPH patients with systolic BP between 150 and 220 mm Hg and no contraindication to acute BP reduction therapy, acute lowering to 140 mm Hg systolic BP is safe 5.
• For persons with small vessel or lacunar cerebral ischemia, a reasonable BP lowering target is <130 mm Hg systolic 5.
• BP targets for the proper management of stroke vary by chronological stage of stroke and by stroke subtype, with consideration given to control of BP variability, especially in the acute phases of stroke 5.

Angiotensin-Converting Enzyme Inhibitors and Stroke Risk

• Angiotensin-converting enzyme (ACE) inhibitors have been shown to reduce the risk of primary stroke, with a meta-analysis of four placebo-controlled trials demonstrating a significant reduction in primary stroke risk 6.
• The benefit of ACE inhibitors may be related to their effects on the renin-angiotensin-aldosterone system more than on blood pressure reduction, although it is premature to conclude that the benefit of ACE inhibitor therapy in primary or secondary prevention of stroke is an effect independent of blood pressure reduction 6.