Do you practice permissive hypertension for possible Transient Ischemic Attack (TIA)/Cerebrovascular Accident (CVA)?

From the Guidelines

Permissive hypertension is recommended for patients with suspected TIA or acute ischemic stroke, with blood pressure not being aggressively lowered unless it exceeds 220/120 mmHg or there are other compelling indications for rapid reduction. According to the most recent guidelines, in patients with acute intracerebral haemorrhage, immediate BP lowering is not recommended for patients with systolic BP <220 mmHg 1. For patients with systolic BP ≥220 mmHg, careful acute BP lowering with i.v. therapy to <180 mmHg should be considered 1.

In the context of TIA or acute ischemic stroke, the approach to blood pressure management is similar, with a focus on maintaining cerebral perfusion pressure and avoiding aggressive lowering of blood pressure unless necessary. The 2024 ESC guidelines recommend anti-hypertensive treatment immediately for TIA and after several days in ischemic stroke 1.

Some key points to consider in the management of blood pressure in these patients include:

• Withholding antihypertensive medications unless BP exceeds 220/120 mmHg
• Cautiously reducing BP by 15-25% within the first 24 hours using easily titratable IV medications like labetalol or nicardipine
• Maintaining blood pressure below 185/110 mmHg before thrombolysis with tPA and below 180/105 mmHg after treatment
• Considering the use of i.v. labetalol, oral methyldopa, or nifedipine for severe hypertension, with intravenous hydralazine as a second-line option 1.

Overall, the goal of permissive hypertension in the management of TIA or acute ischemic stroke is to balance the need to control blood pressure with the need to maintain cerebral perfusion pressure and avoid worsening the patient's condition. This approach is supported by the most recent guidelines and should be tailored to the individual patient's needs and circumstances 1.

From the Research

Permissive Hypertension in Possible TIA/CVA

• Permissive hypertension is a strategy used in the management of acute ischemic stroke, where blood pressure is allowed to remain elevated to ensure adequate cerebral perfusion 2.
• Current guidelines support permissive hypertension in the early course of acute ischemic stroke, with a reasonable goal of lowering blood pressure by 15% during the first 24 hours after onset of stroke 2.
• The level of blood pressure that would mandate treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is greater than 220 mm Hg or the diastolic blood pressure is greater than 120 mm Hg 2.
• 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.

Management of TIA/CVA

• Patients presenting with nondisabling AIS or high-risk TIA should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation 3.
• Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% 3.
• Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation 3.
• Statin treatment is recommended for all patients with a history of ischemic stroke or TIA, with high doses recommended even if cholesterol concentrations are normal 4.

Blood Pressure Management

• Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140/90 mmHg, with ACE inhibitors, calcium channel blockers, and diuretics as first-line options 4.
• The use of ticagrelor and aspirin has been shown to reduce the risk of stroke or death within 30 days in patients with mild-to-moderate acute noncardioembolic ischemic stroke or TIA 5.