PM&R News   •   June 2021

Goals:

• A balance of cerebral perfusion and ischemia
• BP <140/90 mmHg
  • Antihypertensives restarted in neurologically stable patients ~24-48 hrs
    • UTD recommendation: after large artery stenosis is excluded and after vascular imaging performed
      • For large artery: timeframe is 7-14 days
    • Timeframe goal: few days – few weeks

Ischemic

• rtPA not administered: do not lower BP in first 24 hrs
  • unless it exceeds 220/120 OR
  • active: ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, or pre-eclampsia/eclampsia
• Prior to rtPA administration: BP <185/110
• After rtPA administration: BP < 180/105 for 24 hours.
  • Monitoring: 1^st 2 hrs: every 15 minutes, next 6 hrs: every 30 minutes, then every hour until 24 hours total
    • Increase monitoring timeframes if BP >180/105
  • Larger artery occlusion: systolic BP (SBP): 150 – 180 mmHg prior to reperfusion
    • goal SBP: <140 mmHg once reperfusion is achieved (via intravenous alteplase or mechanical thrombectomy)
  • If lowering needed: no >15% in first 24 hrs

Hemorrhagic: Intracerebral hemorrhage (ICH) & Subarachnoid hemorrhage (SAH)

• ICH
  • Presenting with SBP between 150 – 220 mmHg
    • Lower to 140 mmHg (if lower, may increase renal adverse effects)
  • SBP >220 mmHg
    • Aggressive IV antihypertensive and BP monitoring every 5 minutes
    • Goal: 140-160mmHg (optimal goal is uncertain)
• SAH
  • SBP <160 mmHG (or MAP < 100 mmHg)
    • Optimal goal is unknown; can modify based on pt.’s baseline

Medications (antihypertensives):

• No good evidence on choice of medication in ischemic stroke (IV recommended. Examples of rapid/safe medications include: labetalol, nicardipine, and clevidipine)
• For aggressive lowering in ICH (SBP >220). IV of any of the following is recommended: nicardipine, clevidipine, labetalol, esmolol, enalaprilat, fenoldopam, and phentolamine.
  • First 4 agents recommended for reduction in SAH (>140 or cognitive status changes); avoid nitroprusside or nitroglycerin.

Statistics

• Systolic >200 vs 130 mmHg had a 50% greater risk of recurrent stroke
• Low BP (<120 mmHg): associated with additional deaths from coronary heart disease
• Mixed findings on lowering BP within 1^st 24 hrs; some results showed continuing antihypertensives in the acute phase can be more detrimental.

Patient education:

• Lifestyle modification to decrease BP: salt intake reduction, weight loss, diet changes, and smoking cessation
• Each 10 mmHg reduction in BP = 1/3 reduction in stroke risk
• HTN: most modifiable risk factor for stroke

Link: Options to treat to hypertension before and during reperfusion therapy for acute ischemic stroke

📷: Mufid Majnun on Unsplash

References

1. https://www.ncbi.nlm.nih.gov/pubmed/32048202
2. https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke?search=cva%20bp%20management&sectionRank=1&usage_type=default&anchor=H15&source=machineLearning&selectedTitle=1~150&display_rank=1#H15
3. https://www.uptodate.com/contents/intravenous-thrombolytic-therapy-for-acute-ischemic-stroke-therapeutic-use?sectionName=Management%20of%20blood%20pressure&search=cva%20bp%20management&topicRef=1126&anchor=H2033684512&source=see_link#H548390
4. https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis?sectionName=Blood%20pressure%20control&search=cva%20bp%20management&topicRef=1126&anchor=H1332326243&source=see_link#H28753187