How is blood pressure controlled in acute management of stroke?

Updated: Sep 08, 2017
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Answer

In poor flow states―which occur with thrombotic and embolic ischemic stroke, as well as with increased ICP due to cerebral edema―the cerebral vasculature loses vasoregulatory capability and thus relies directly on mean arterial pressure (MAP) and cardiac output for maintenance of cerebral blood flow. Therefore, aggressive efforts to lower blood pressure may decrease perfusion pressure and may prolong or worsen ischemia. Rapid reduction of blood pressure, no matter the degree of hypertension, may in fact be harmful. Both elevated and low blood pressures are associated with poor outcomes in patients with acute stroke. [25] (See Table 3, below.)

Studies have demonstrated that blood pressure typically drops in the first 24 hours after acute stroke, whether or not antihypertensives are administered. Furthermore, studies have revealed poorer outcomes in patients with lower blood pressures, with these outcomes correlating with the degree of pressure decline. [25, 26]

In a 2012 analysis of data from The Scandinavian Candesartan Acute Stroke Trial, acute stroke patients with a large decrease or increase or no change in systolic blood pressure experienced an increased risk of early adverse events compared with patients with a small decrease, and patients with an increase or no change in systolic blood pressure had an increased risk of poor neurological outcome compared with other patients. Routine attempts to lower blood pressure in the acute phase of stroke should probably be avoided. [27]

The consensus recommendation is to lower blood pressure only if systolic pressure is in excess of 220 mm Hg or if diastolic pressure is greater than 120 mm Hg. [19] However, a systolic blood pressure greater than 185 mm Hg or a diastolic pressure greater than 110 mm Hg is a contraindication to the use of thrombolytics. Therefore, the management of elevated blood pressure in acute ischemic stroke may vary, depending on whether the patient is a candidate for thrombolytic therapy.

Table 3. Blood Pressure Management in Patients With Stroke* (Open Table in a new window)

 

Blood Pressure

Treatment

Candidates for fibrinolysis

Pretreatment:

SBP >185 or DBP >110 mm Hg

Labetalol 10-20 mg IVP repeated every 10-20 minutes

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h or

Enalapril 1.25 mg IVP

 

Posttreatment:

DBP >140 mm Hg

SBP >230 mm Hg or

DBP 121-140 mm Hg

SBP 180-230 mm Hg or DBP 105-120 mm Hg

Sodium nitroprusside (0.5 mcg/kg/min)

Labetalol 10-20 mg IVP and consider labetalol infusion at 1-2 mg/min or nicardipine 5 mg/h IV infusion and titrate

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h or

Labetalol 10 mg IVP, may repeat and double every 10 min up to maximum dose of 300 mg

Noncandidates for fibrinolysis

DBP >140 mm Hg

SBP >220 or

DBP 121-140 mm Hg or

MAP >130 mm Hg

SBP < 220 mm Hg or

DBP 105-120 mm Hg or

MAP < 130 mm Hg

Sodium nitroprusside 0.5 mcg/kg/min; may reduce approximately 10-20%

Labetalol 10-20 mg IVP over 1-2 min; may repeat and double every 10 min up to maximum dose of 150 mg or nicardipine 5 mg/h IV infusion and titrate

or

Nicardipine 5 mg/h, titrate by 2.5 mg/h every 5-15 min, maximum 15 mg/h; when desired blood pressure reached, lower to 3 mg/h

Antihypertensive therapy indicated only if acute myocardial infarction, aortic dissection, severe CHF, or hypertensive encephalopathy present

*Adapted from 2005 Advanced Cardiac Life Support (ACLS) guidelines and 2007 American Stroke Association Scientific Statement

Abbreviations: SBP - systolic blood pressure; DBP - diastolic blood pressure; IVP - IV push; MAP - mean arterial pressure


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