Secondary Stroke Prevention: Antihypertensive Selection and Timing

First‑Line Oral Antihypertensive Classes

ACE inhibitors, angiotensin‑receptor blockers (ARBs), calcium‑channel blockers, and thiazide diuretics are all recommended as first‑line oral agents for secondary stroke prevention, with a chronic blood‑pressure target of <130/80 mmHg. 1

Transient ischemic attack (TIA): Begin oral antihypertensive therapy immediately after the event. 1
Ischemic stroke: Initiate antihypertensive treatment after a delay of several days following the acute phase. 1
Intracerebral hemorrhage: Start antihypertensive medication for long‑term management once the acute hemorrhagic phase has resolved. 1

Aggressive lowering of blood pressure in the acute ischemic‑stroke period is contraindicated unless systolic ≥ 220 mmHg or diastolic ≥ 120 mmHg; otherwise, maintain current pressures to avoid compromising penumbral perfusion. 1
Rapid blood‑pressure reduction in acute ischemic stroke can precipitate vital‑organ hypoperfusion because cerebral autoregulation is impaired. 2
In hospitalized stroke patients with asymptomatic severe hypertension (>180/120 mmHg) but without acute target‑organ damage, intermittent intravenous or oral antihypertensive boluses should be avoided. 2

TIA: Initiate any first‑line oral antihypertensive immediately. 1
Ischemic stroke: Wait several days before starting antihypertensive therapy. 1
Target attainment: Add a second antihypertensive agent if needed to achieve the <130/80 mmHg goal. 1
Resistant hypertension: Introduce spironolactone as the preferred fourth‑line agent when blood pressure remains uncontrolled on three agents. 1