Acute Management of Hypertension in Acute Ischemic Stroke

Primary Recommendations

The European Society of Cardiology recommends that for a patient with blood pressure 180/100 and acute ischemic stroke NOT receiving thrombolysis or thrombectomy, blood pressure should not be actively lowered at this time, as this blood pressure does not meet the threshold for intervention 1, 2
The European Society of Cardiology suggests that cerebral autoregulation is impaired in acute stroke, and maintaining cerebral perfusion depends on systemic blood pressure, therefore lowering blood pressure in this range may worsen cerebral ischemia and outcomes 1, 2

For patients with blood pressure <220/120 mmHg and not receiving thrombolysis or thrombectomy, no active blood pressure lowering is indicated, as recommended by the European Society of Cardiology 1, 2
For patients with blood pressure ≥220/120 mmHg, cautious reduction of blood pressure by approximately 10-15% over several hours is recommended by the European Society of Cardiology 1, 2

The American Heart Association recommends that blood pressure must be <185/110 mmHg before thrombolysis and maintained <180/105 mmHg for 24 hours after, with first-line agents for pre-thrombolysis blood pressure control being labetalol or nicardipine 2, 3
The American Heart Association suggests that during and after thrombolysis, blood pressure should be monitored every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 3

The European Society of Cardiology recommends that after the acute phase (≥3 days post-stroke), blood pressure-lowering medication should be initiated or reintroduced if blood pressure ≥140/90 mmHg, with preferred agents for secondary prevention being ACE inhibitor or ARB, thiazide or thiazide-like diuretic, and beta-blocker if coronary artery disease is present 1, 2, 4

The European Society of Cardiology advises against aggressively lowering blood pressure <220/120 mmHg in acute ischemic stroke without reperfusion therapy, as this can worsen cerebral ischemia and outcomes 1, 2
The American Heart Association recommends against using labetalol if heart rate <60 bpm, as this is an absolute contraindication 5, 6