Antihypertensive Management After Acute Ischemic Stroke

1. General Recommendations for Patients Not Receiving Thrombolysis

In neurologically stable patients with acute ischemic stroke who have not received thrombolysis, antihypertensive therapy should be restarted or initiated 24–72 hours after onset if systolic/diastolic BP is ≥140/90 mmHg, with a long‑term target of <130/80 mmHg for secondary prevention. (Class IIa, American College of Cardiology) 1, 2
Blood pressure should not be treated when it is <220/120 mmHg during the first 48–72 hours (the permissive hypertension phase). This is a Class III recommendation (no benefit). 1, 2, 3
Initiating or re‑initiating antihypertensive medication during the permissive hypertension window does not reduce death or dependency. (Class III) 1, 3
If BP is ≥220/120 mmHg, reduce mean arterial pressure by no more than 15 % over 24 hours (Class IIb). 1, 2, 4
After the permissive phase (≥48 hours), antihypertensive agents may be restarted after 24 hours in patients with pre‑existing hypertension who remain neurologically stable (Class IIa). 1, 2, 4
The long‑term BP target for secondary stroke prevention remains <130/80 mmHg. (Class I) 2, 4

Pre‑tPA: Lower BP to <185/110 mmHg before initiating thrombolysis. (Class I) 1, 2, 3
Post‑tPA: Maintain BP <180/105 mmHg for at least 24 hours to reduce the risk of hemorrhagic transformation. (Class I) 1, 2, 3
Elevated BP during the first 24 hours after tPA is significantly associated with symptomatic intracranial hemorrhage. (observational evidence) 1

In the acute phase, cerebral autoregulation is markedly impaired in the ischemic penumbra, making systemic perfusion pressure essential for delivering blood flow and oxygen to salvageable tissue. (Pathophysiologic evidence) 1, 3, 4
Observational studies show a U‑shaped relationship between admission BP and functional outcomes, with the optimal systolic range 121–200 mmHg. (Observational evidence) 1, 3, 4
Rapid BP reduction, even to levels still within the hypertensive range, can enlarge infarct size by decreasing perfusion to the penumbra. (Observational evidence) 1, 3

First‑line agents after the acute phase include thiazide diuretics, ACE inhibitors, ARBs, or a combination of a thiazide plus an ACE inhibitor. (Class I) 2, 4

Do not automatically restart home antihypertensive medications during the first 48–72 hours, as this may jeopardize cerebral perfusion to the penumbra. (Class III) 1
Exceptions requiring immediate BP control despite the permissive phase are: hypertensive encephalopathy, acute myocardial infarction, acute pulmonary edema, aortic dissection, and acute renal failure. (Class I for these comorbidities) 1
Avoid precipitous BP drops; agents that cannot be titrated (e.g., sublingual nifedipine) should not be used. When treatment is indicated (BP ≥ 220/120 mmHg), limit reduction to ≤15 % over 24 hours. (Class IIb) 1
Recognize that elevated BP in acute stroke is often a compensatory response to maintain cerebral perfusion; hypotension is potentially more harmful and warrants urgent correction. (Pathophysiologic insight) 1

For stable patients who remain hypertensive (≥140/90 mmHg) ≥3 days after an acute ischemic stroke, initiation or reintroduction of BP-lowering medication is recommended, as per the European Society of Cardiology 5, 6
During the first 72 hours after stroke onset, patients with acute ischemic stroke and BP <180/105 mmHg do not benefit from introduction or reintroduction of BP-lowering medication, based on the understanding that cerebral autoregulation is impaired in acute stroke 5, 6
For patients who received reperfusion therapy, BP should be maintained <180/105 mmHg for at least the first 24 hours after treatment, according to the European Heart Journal 5, 6
For patients not receiving reperfusion therapy with extremely high BP (>220/120 mmHg), a moderate reduction of 10-15% over several hours may be considered, as suggested by the European Heart Journal 5

Early after stroke, cerebral autoregulation is impaired, and the ischemic penumbra depends on systemic BP for perfusion, as stated by the American College of Cardiology and the Hypertension journal 7, 8
After 3 days, the risk of cerebral hypoperfusion decreases, while the benefits of BP control for secondary prevention become more relevant, according to the European Heart Journal and the Hypertension journal 5, 7

Close BP monitoring should continue for at least the first 24-48 hours after stroke onset, as recommended by the International Journal of Stroke 9
When initiating antihypertensive therapy after day 3, treatment should be started before hospital discharge, as suggested by the Hypertension journal and the Journal of the American College of Cardiology 7, 10
For long-term secondary prevention, a thiazide diuretic, ACE inhibitor, ARB, or combination treatment consisting of a thiazide diuretic plus ACE inhibitor is recommended by the Journal of the American College of Cardiology 10
Some evidence suggests that a more aggressive target of <130/80 mmHg may be reasonable for secondary prevention, particularly for patients with lacunar stroke, as stated by the Journal of the American College of Cardiology 10

Avoid excessive BP reduction (>70 mmHg drop) in the acute phase as it may cause acute renal injury and neurological deterioration, as warned by the European Heart Journal 5
Do not initiate antihypertensive therapy too early (before 3 days) in patients with BP <220/120 mmHg who did not receive reperfusion therapy, as this has been shown to be ineffective for preventing death or dependency, according to the Journal of the American College of Cardiology 8, 11