Management of Blood Pressure in Acute Stroke

Blood Pressure Targets

• The American Heart Association recommends that blood pressure should not be treated unless severely elevated (systolic >220 mmHg or diastolic >120 mmHg) in patients not receiving thrombolytic therapy 1, 2, 3
• For patients eligible for thrombolytic therapy, blood pressure must be <185/110 mmHg before initiating thrombolysis, and then maintained <180/105 mmHg for at least 24 hours 2, 7, 8

First-Line Medications

• Labetalol is a first-line agent for blood pressure reduction, with an initial dose of 10-20 mg IV over 1-2 minutes, and may be repeated or doubled every 10-20 minutes to a maximum of 300 mg 2, 4, 6, 1
• Nicardipine is also a first-line agent, with an initial dose of 5 mg/hr IV infusion, and can be titrated by increasing 2.5 mg/hr every 5-15 minutes to a maximum of 15 mg/hr 2, 9

Special Considerations

• In hemorrhagic stroke, more aggressive blood pressure lowering to 140-160 mmHg systolic is recommended 7, 8
• During mechanical thrombectomy, blood pressure should be maintained <180/105 mmHg before, during, and after the procedure 7, 8

Monitoring and Treatment

• Blood pressure should be monitored every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours in patients receiving thrombolytic therapy 6, 4
• The goal is to achieve a controlled reduction in blood pressure, as rapid drops can worsen neurological outcomes 4, 5