Blood Pressure Goals in Acute Stroke—How Low Do You Go?
- 28 Downloads
Purpose of Review
Elevations in systolic blood pressure (BP) greater than 140 mmHg are reported in the majority (75%) of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages (ICH). This paper summarizes and updates the current knowledge regarding the proper management strategy for elevated BP in patients with acute stroke.
Recent Findings and Summary
Recent studies have generally showed a neutral effect of BP reduction on clinical outcomes among acute ischemic stroke patients. Thus, because of the lack of convincing evidence from clinical trials, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. Although in patients treated with intravenous tissue plasminogen activator, guidelines are recommending BP < 180/105 mmHg but currently, the optimal BP management after reperfusion therapy still remains unclear. In acute ICH, the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg, which is now recommended by guidelines.
KeywordsBlood pressure Ischemic stroke Intracerebral hemorrhage
Compliance with Ethics Guidelines
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.•• Alsibai A, Qureshi AI. Management of Acute Hypertensive Response in Patients With Ischemic Stroke. The Neurohospitalist. 2016;6(3):122–9. This review summarizes the current data on acute hypertensive response or elevated BP management during the first 72 hours after an acute ischemic stroke. CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Trial Investigators ENOS, Bath PM, Woodhouse L, Scutt P, Krishnan K, Wardlaw JM, et al. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomized controlled trial. Lancet. 2015;385:617–28.CrossRefGoogle Scholar
- 16.Zhao R. Blood pressure reduction in the acute phase of an ischemic stroke does not improve short- or long-term dependency or mortality. A Meta-Analysis of Current Literature. 2015;94(23):1–15.Google Scholar
- 18.Jauch EC, Saver JL, Adams HP Jr, et al. American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.CrossRefPubMedGoogle Scholar
- 19.Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke. 2009;40:2442–9.CrossRefPubMedGoogle Scholar
- 21.Regenhardt RW, et al. Blood pressure and penumbral sustenance in stroke from large vessel occlusion. Front Neurol. 2017;8(317)Google Scholar
- 28.Sakamoto Y, Koga M, Yamagami H, et al. SAMURAI Study Investigators Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. Stroke. 2013;44(7):1846–51.CrossRefPubMedGoogle Scholar
- 30.Qureshi AI. Acute blood pressure management—the North American perspective. Update on cerebral hemorrhage trials session. Presented at the International Stroke Conference; New Orleans; February 20, 2008. Available at: www.scienceondemand.org/stroke2008/sessions/player. html?sid_08020172.758. Accessed July 4, 2008.Google Scholar
- 31.Qureshi AI, The ATACH Investigators. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Trial. International Stroke Conference. New Orleans, LA, February 2008.Google Scholar
- 33.Manios E, et al. Blood pressure targets in acute intracerebral hemorrhage. Scientific newsletter. 2017;e64:18.Google Scholar
- 45.Gioia et al. The intracerebral hemorrhage acutely decreasing arterial pressure trial II (ICH ADAPT II) protocol. BMC Neurology. 2017 (17):100.Google Scholar
- 47.oulouis G, Morotti A, Goldstein JN, Charidimou A. Intensive blood pressure lowering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of randomised trials. J Neurol Neurosurg Psychiatry. 2017;88:339–45.CrossRefGoogle Scholar
- 48.•• Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015; 46(7):2032–2060. J. Hypertens. 34 (Suppl 1- ISH 2016 Abstract Book). 2016: e396–e397. Description of the current guidelines for the management of spontaneous intracerebral hemorrhage. Google Scholar
- 55.Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007;38(6):2001–23.CrossRefPubMedGoogle Scholar