Skip to main content

Advertisement

SpringerLink
Log in

Blood Pressure in Acute Stroke and Secondary Stroke Prevention

  • Stroke (B. Ovbiagele, Section Editor)
  • Published:
Current Neurology and Neuroscience Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Hypertension is common in patients presenting with stroke and is independently associated with unfavorable outcomes. This article reviews current guidelines for early management of blood pressure (BP) and highlights the findings of recent investigative works.

Recent Findings

Intensive blood pressure reduction after receiving alteplase has not been shown to improve outcomes. Patients with large vessel occlusions may benefit from lower blood pressure targets post-intervention. Retrospective analyses of large intracerebral hemorrhage trials suggest that specific subgroups of patients may disproportionately benefit from or be harmed by intensive BP reduction. Robust data for management of blood pressure in subarachnoid hemorrhage patients is lacking and expert consensus continues to guide decision-making.

Summary

Despite the impact of hypertension on outcomes, most prospective trials assessing efficacy of blood pressure reduction have yielded neutral or inconclusive results. Further trials are necessary to determine which patient populations are most likely to benefit from blood pressure control.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ Res. 2017;120(3):439–48. https://doi.org/10.1161/circresaha.116.308413.

    Article  CAS  PubMed  Google Scholar 

  2. Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, et al. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation. 2021;143(8):e254–743. https://doi.org/10.1161/cir.0000000000000950.

    Article  PubMed  Google Scholar 

  3. Wallace JD, Levy LL. Blood pressure after stroke. Jama. 1981;246(19):2177–80.

    Article  CAS  Google Scholar 

  4. Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25(1):32–8. https://doi.org/10.1016/j.ajem.2006.07.008.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Vemmos KN, Tsivgoulis G, Spengos K, Zakopoulos N, Synetos A, Manios E, Konstantopoulou P, Mavrikakis M. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med. 2004;255(2):257–65. https://doi.org/10.1046/j.1365-2796.2003.01291.x.

    Article  CAS  PubMed  Google Scholar 

  6. Castillo J, Leira R, García MM, Serena J, Blanco M, Dávalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004;35(2):520–6. https://doi.org/10.1161/01.Str.0000109769.22917.B0.

    Article  PubMed  Google Scholar 

  7. Gorelick PB, Aiyagari V. The management of hypertension for an acute stroke: what is the blood pressure goal? Curr Cardiol Rep. 2013;15(6):366. https://doi.org/10.1007/s11886-013-0366-2.

    Article  PubMed  Google Scholar 

  8. • Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the eakrly management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344–418. https://doi.org/10.1161/str.0000000000000211This article summarizes the most recent AHA/ASA guidelines for management of acute ischemic stroke.

    Article  PubMed  Google Scholar 

  9. Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, Lees KR, Toni D, SITS Investigators. 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(7):2442–9. https://doi.org/10.1161/strokeaha.109.548602.

    Article  PubMed  Google Scholar 

  10. •• Anderson CS, Huang Y, Lindley RI, Chen X, Arima H, Chen G, et al. Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial. Lancet. 2019;393(10174):877–88. https://doi.org/10.1016/s0140-6736(19)30038-8This study evaluated the effect of intensive blood pressure reduction in acute ischemic stroke patients who received alteplase.

    Article  PubMed  Google Scholar 

  11. Lin MP, Tsivgoulis G, Alexandrov AV, Chang JJ. Factors affecting clinical outcome in large-vessel occlusive ischemic strokes. Int J Stroke. 2015;10(4):479–84. https://doi.org/10.1111/ijs.12406.

    Article  PubMed  Google Scholar 

  12. Goyal N, Tsivgoulis G, Iftikhar S, Khorchid Y, Fawad Ishfaq M, Doss VT, Zand R, Chang J, Alsherbini K, Choudhri A, Hoit D, Alexandrov AV, Arthur AS, Elijovich L. Admission systolic blood pressure and outcomes in large vessel occlusion strokes treated with endovascular treatment. J Neurointerv Surg. 2017;9(5):451–4. https://doi.org/10.1136/neurintsurg-2016-012386.

    Article  PubMed  Google Scholar 

  13. Goyal N, Tsivgoulis G, Pandhi A, Chang JJ, Dillard K, Ishfaq MF, Nearing K, Choudhri AF, Hoit D, Alexandrov AW, Arthur AS, Elijovich L, Alexandrov AV. Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology. 2017;89(6):540–7. https://doi.org/10.1212/wnl.0000000000004184.

    Article  PubMed  Google Scholar 

  14. •• Anadani M, Orabi MY, Alawieh A, Goyal N, Alexandrov AV, Petersen N, et al. Blood Pressure and outcome after mechanical thrombectomy with successful revascularization. Stroke. 2019;50(9):2448–54. https://doi.org/10.1161/strokeaha.118.024687This paper describes the relationship between pre- and post-intervention blood pressure and outcomes in patients undergoing successful endovascular therapy.

    Article  PubMed  Google Scholar 

  15. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21. https://doi.org/10.1056/NEJMoa1706442.

    Article  PubMed  Google Scholar 

  16. Oh MS, Yu KH, Hong KS, Kang DW, Park JM, Bae HJ, Koo J, Lee J, Lee BC, Valsartan Efficacy oN modesT blood pressUre REduction in acute ischemic stroke (VENTURE) study group. Modest blood pressure reduction with valsartan in acute ischemic stroke: a prospective, randomized, open-label, blinded-end-point trial. Int J Stroke. 2015;10(5):745–51. https://doi.org/10.1111/ijs.12446.

    Article  PubMed  Google Scholar 

  17. Sandset EC, Bath PM, Boysen G, Jatuzis D, Kõrv J, Lüders S, Murray GD, Richter PS, Roine RO, Terént A, Thijs V, Berge E, SCAST Study Group. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011;377(9767):741–50. https://doi.org/10.1016/s0140-6736(11)60104-9.

    Article  CAS  PubMed  Google Scholar 

  18. Bath PM, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database Syst Rev. 2014;2014(10):Cd000039. https://doi.org/10.1002/14651858.CD000039.pub3.

    Article  PubMed Central  Google Scholar 

  19. Bang OY, Goyal M, Liebeskind DS. Collateral circulation in ischemic stroke: assessment tools and therapeutic strategies. Stroke. 2015;46(11):3302–9. https://doi.org/10.1161/strokeaha.115.010508.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Lee MH, Kim JG, Jeon SB, Kang DW, Kwon SU, Kim JS. Pharmacologically Induced Hypertension Therapy for Acute Stroke Patients. J Stroke. 2019;21(2):228–30. https://doi.org/10.5853/jos.2019.00437.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kang MJ, Yang JW, Lee YB, Park KH, Park HM, Shin DJ, Sung YH, Lee H, Shin DH. The role of phenylephrine in patients with small deep subcortical infarct and progressive weakness. J Neurol Sci. 2017;377:107–11. https://doi.org/10.1016/j.jns.2017.04.008.

    Article  CAS  PubMed  Google Scholar 

  22. •• Bang OY, Chung JW, Kim SK, Kim SJ, Lee MJ, Hwang J, et al. Therapeutic-induced hypertension in patients with noncardioembolic acute stroke. Neurology. 2019;93(21):e1955–e63. https://doi.org/10.1212/wnl.0000000000008520This study evaluated the effect of pharmacologically induced hypertension on outcomes in acute ischemic stroke patients.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009;373(9675):1632–44. https://doi.org/10.1016/s0140-6736(09)60371-8.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Qureshi AI. Acute hypertensive response in patients with stroke: pathophysiology and management. Circulation. 2008;118(2):176–87. https://doi.org/10.1161/circulationaha.107.723874.

    Article  PubMed  Google Scholar 

  25. Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, Lindley R, Robinson T, Lavados P, Neal B, Hata J, Arima H, Parsons M, Li Y, Wang J, Heritier S, Li Q, Woodward M, Simes RJ, Davis SM, Chalmers J, INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. doi: https://doi.org/10.1056/NEJMoa1214609.

  26. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW, ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033-1043. doi: https://doi.org/10.1056/NEJMoa1603460.

  27. • Li Q, Warren AD, Qureshi AI, Morotti A, Falcone GJ, Sheth KN, et al. Ultra-early blood pressure reduction attenuates hematoma growth and improves outcome in intracerebral hemorrhage. Ann Neurol. 2020;88(2):388–95. https://doi.org/10.1002/ana.25793This retrospective analysis demonstrated proportional benefit for rapid early blood pressure reduction in patients presenting with acute intracerebral hemorrhage.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Okazaki S, Yamamoto H, Foster LD, Fukuda-Doi M, Koga M, Ihara M, Toyoda K, Palesch YY, Qureshi AI. Late neurological deterioration after acute intracerebral hemorrhage: a post hoc analysis of the ATACH-2 trial. Cerebrovasc Dis. 2020;49(1):26–31. https://doi.org/10.1159/000506117.

    Article  PubMed  Google Scholar 

  29. Qureshi AI, Foster LD, Lobanova I, Huang W, Suarez JI. Intensive blood pressure lowering in patients with moderate to severe grade acute cerebral hemorrhage: post hoc analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial. Cerebrovasc Dis. 2020;49(3):244–52. https://doi.org/10.1159/000506358.

    Article  CAS  PubMed  Google Scholar 

  30. Lattanzi S, Cagnetti C, Provinciali L, Silvestrini M. Blood pressure variability and clinical outcome in patients with acute intracerebral hemorrhage. J Stroke Cerebrovasc Dis. 2015;24(7):1493–9. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.03.014.

    Article  PubMed  Google Scholar 

  31. Divani AA, Liu X, Di Napoli M, Lattanzi S, Ziai W, James ML, et al. Blood pressure variability predicts poor in-hospital outcome in spontaneous intracerebral hemorrhage. Stroke. 2019;50(8):2023–9. https://doi.org/10.1161/strokeaha.119.025514.

    Article  PubMed  Google Scholar 

  32. Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, 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):2032–60. https://doi.org/10.1161/str.0000000000000069.

    Article  PubMed  Google Scholar 

  33. Wijdicks EF, Vermeulen M, Murray GD, Hijdra A, van Gijn J. The effects of treating hypertension following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg. 1990;92(2):111–7. https://doi.org/10.1016/0303-8467(90)90085-j.

    Article  CAS  PubMed  Google Scholar 

  34. Oheda M, Inamasu J, Moriya S, Kumai T, Kawazoe Y, Nakae S, Kato Y, Hirose Y. Early rebleeding in patients with subarachnoid haemorrhage under intensive blood pressure management. J Clin Neurosci. 2015;22(8):1338–42. https://doi.org/10.1016/j.jocn.2015.02.024.

    Article  PubMed  Google Scholar 

  35. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711–37. https://doi.org/10.1161/STR.0b013e3182587839.

    Article  PubMed  Google Scholar 

  36. Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211–40. https://doi.org/10.1007/s12028-011-9605-9.

    Article  PubMed  Google Scholar 

  37. Soehle M, Czosnyka M, Pickard JD, Kirkpatrick PJ. Continuous assessment of cerebral autoregulation in subarachnoid hemorrhage. Anesth Analg. 2004;98(4):1133–9. https://doi.org/10.1213/01.Ane.0000111101.41190.99.

    Article  PubMed  Google Scholar 

  38. Gathier CS, Dankbaar JW, van der Jagt M, Verweij BH, Oldenbeuving AW, Rinkel GJ, et al. Effects of induced hypertension on cerebral perfusion in delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a randomized clinical trial. Stroke. 2015;46(11):3277–81. https://doi.org/10.1161/strokeaha.115.010537.

    Article  PubMed  Google Scholar 

  39. •• Gathier CS, van den Bergh WM, van der Jagt M, Verweij BH, Dankbaar JW, Müller MC, et al. Induced hypertension for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a randomized clinical trial. Stroke. 2018;49(1):76–83. https://doi.org/10.1161/strokeaha.117.017956This study attempted to examine the effect of induced hypertension on patients who experienced delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage but was closed early due to difficulties with patient recruitment.

    Article  PubMed  Google Scholar 

  40. Brown RJ, Kumar A, McCullough LD, Butler K. A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage. Int J Neurosci. 2017;127(1):51–8. https://doi.org/10.3109/00207454.2016.1138952.

    Article  PubMed  Google Scholar 

  41. He J, Zhang Y, Xu T, Zhao Q, Wang D, Chen CS, Tong W, Liu C, Xu T, Ju Z, Peng Y, Peng H, Li Q, Geng D, Zhang J, Li D, Zhang F, Guo L, Sun Y, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. Jama. 2014;311(5):479–89. https://doi.org/10.1001/jama.2013.282543.

    Article  CAS  PubMed  Google Scholar 

  42. Katsanos AH, Filippatou A, Manios E, Deftereos S, Parissis J, Frogoudaki A, Vrettou AR, Ikonomidis I, Pikilidou M, Kargiotis O, Voumvourakis K, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression analysis of randomized clinical trials. Hypertension. 2017;69(1):171–9. https://doi.org/10.1161/hypertensionaha.116.08485.

    Article  CAS  PubMed  Google Scholar 

  43. Chalmers J, MacMahon S. Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS): interpretation and implementation. J Hypertens Suppl. 2003;21(5):S9–14. https://doi.org/10.1097/00004872-200306005-00003.

    Article  CAS  PubMed  Google Scholar 

  44. Benavente OR, White CL, Pearce L, Pergola P, Roldan A, Benavente MF, Coffey C, McClure LA, Szychowski JM, Conwit R, Heberling PA, Howard G, Bazan C, Vidal-Pergola G, Talbert R, Hart RG, for the SPS3 Investigators. The Secondary Prevention of Small Subcortical Strokes (SPS3) study. Int J Stroke. 2011;6(2):164–75. https://doi.org/10.1111/j.1747-4949.2010.00573.x.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Diener HC, Hankey GJ. Primary and secondary prevention of ischemic stroke and cerebral hemorrhage: JACC Focus Seminar. J Am Coll Cardiol. 2020;75(15):1804–18. https://doi.org/10.1016/j.jacc.2019.12.072.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Zuckerberg San Francisco General Hospital, University of California, Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA, 94110, USA

    Christopher R Green & J Claude Hemphill

Authors
  1. Christopher R Green
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J Claude Hemphill
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J Claude Hemphill.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Stroke

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Green, C.R., Hemphill, J.C. Blood Pressure in Acute Stroke and Secondary Stroke Prevention. Curr Neurol Neurosci Rep 22, 143–150 (2022). https://doi.org/10.1007/s11910-022-01169-8

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11910-022-01169-8

Keywords

Search

Navigation