Management of Acute Ischemic Stroke: A Review of Pertinent Guideline Updates

Carley E. DeVee, PharmD, BCPS; Ryan J. Sangiovanni, PharmD


US Pharmacist. 2019;44(2):HS2-HS5. 

In This Article

Blood Pressure

Blood pressure is elevated in over 75% of acute stroke patients and is associated with poor outcomes.[17] Hypertension is the single most modifiable risk factor for stroke prevention.[18] Management of hypertension is the most common and impactful way to limit the reccurrence of stroke.[19] While evidence continues to increase our understanding of the role of blood pressure management in AIS, how to best modify the blood pressure in a patient experiencing an AIS continues to be debated.

Patients experiencing AIS who are hypertensive but otherwise candidates for IV alteplase do have a specific target blood pressure to limit the risk of hemorrhage in elevated and variable blood pressure. The goal is less than 185 mm Hg systolic blood pressure (SBP) and less than 110 mm Hg diastolic blood pressure before the initiation of IV fibrinolytic therapy.[2] This is not a new recommendation; however, it is a clarification from the previous guideline recommendations.[1] This goal aims to decrease the risk of hemorrhage when using IV alteplase in patients with elevated or variable blood pressures.[2]

Not withholding an antihypertensive medication in patients with comorbidities that warrant such therapy after initial presentation is currently recommended. These blood pressure goals should be individualized; however, a decrease in SBP of approximately 15% within the first 24 hours is generally accepted. In patients with extreme hypertension (≥220/120 mm Hg) or those not receiving an IV fibrinolytic, a 15% decrease in SBP after initial AIS treatment may be reasonable. This allows for some blood-pressure lowering, but not enough to worsen cerebral ischemia; this is termed permissive hypertension. It is also recommended to initiate antihypertensive therapy in patients with elevated blood pressure (>140/90 mm Hg) who are neurologically stable.[2]

Patients with AIS are often hypertensive upon admission with decreasing blood pressures throughout the natural disease progression. However, patients may present with hypotension, and this is associated with poor outcomes as well.[20] There is little guidance on specific goals to manage hypotension in AIS patients. The most recent guidelines do not suggest an exact blood pressure goal but rather a broad goal of maintaining perfusion to promote vital organ function.[2]