From the Guidelines
Permissive hypertension is recommended in acute ischemic stroke patients, with blood pressure generally not lowered unless it exceeds 220/120 mmHg for patients not eligible for thrombolytic therapy, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Key Considerations
- For patients eligible for thrombolytic therapy, blood pressure should be maintained below 185/110 mmHg before treatment and below 180/105 mmHg for the first 24 hours after treatment, according to the 2024 ESC guidelines 1.
- If intervention is needed, intravenous medications with short half-lives and careful titration are preferred.
- The permissive approach to hypertension in ischemic stroke is based on the understanding that the ischemic penumbra relies on adequate perfusion pressure, and lowering blood pressure too aggressively may extend the area of infarction by reducing blood flow to vulnerable tissue that has lost autoregulation.
Management Strategies
- For patients with acute ischemic stroke and a blood pressure of <180/105 mmHg in the first 72 hours after stroke, there is no benefit from the introduction or reintroduction of blood pressure-lowering medication, as stated in the 2024 ESC guidelines 1.
- For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischemic stroke, initiation or reintroduction of blood pressure-lowering medication is recommended, according to the 2024 ESC guidelines 1.
Comparison with Other Guidelines
- The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also recommends a permissive approach to hypertension in acute ischemic stroke patients, with similar blood pressure targets 1.
- However, the 2024 ESC guidelines provide more specific guidance on the management of blood pressure in acute ischemic stroke patients, and are therefore considered the most up-to-date and relevant guidelines for this topic.
From the Research
Stroke Permissive Hypertension Criteria
The criteria for permissive hypertension in the context of acute ischemic stroke are based on the balance between the risks of high blood pressure and the potential benefits of maintaining adequate cerebral perfusion.
- The general consensus is to avoid lowering blood pressure unless it exceeds certain thresholds, such as a systolic blood pressure greater than 220 mm Hg or a diastolic blood pressure greater than 120 mm Hg 2.
- For patients undergoing intravenous thrombolysis, it is recommended to reduce and maintain blood pressure below 185 mm Hg systolic for the first 24 hours 2.
- Comorbid conditions such as myocardial infarction, left ventricular failure, aortic dissection, preeclampsia, or eclampsia may require more aggressive blood pressure management, overriding the guidelines for permissive hypertension 2.
Blood Pressure Management
The management of blood pressure in acute stroke patients involves the use of antihypertensive agents such as labetalol, nicardipine, and sodium nitroprusside.
- Studies have compared the efficacy and safety of these agents, with some suggesting that nicardipine may be more effective in achieving and maintaining goal blood pressure 3, 4.
- The choice of antihypertensive agent and the timing of administration can impact the time to blood pressure control and the door-to-needle time for thrombolytic therapy 5.
- The optimal antihypertensive regimen for controlling blood pressure before alteplase therapy remains unclear, and further study is needed to define optimal blood pressure goals and management strategies 5, 6.
Considerations for Blood Pressure Control
The control of blood pressure in acute stroke patients must be balanced against the risk of decreasing penumbral blood flow and exacerbating vasogenic edema.
- The current approach is to use predictable and titratable medications that judiciously reduce the initial presenting mean arterial pressure by approximately 10% to 15% 2, 6.
- Future studies must define optimal blood pressure goals, likely on an individual basis, and investigate the effects of different antihypertensive regimens on clinical outcomes 2, 6.