Post-stroke antihypertensive therapy

NICE state (1):

Blood pressure control for people with acute ischaemic stroke

• anti-hypertensive treatment in people with acute stroke is recommended only if there is a hypertensive emergency with one or more of the following serious concomitant medical issues:
  • hypertensive encephalopathy
  • hypertensive nephropathy
  • hypertensive cardiac failure/myocardial infarction
  • aortic dissection
  • pre-eclampsia/eclampsia
    
    
• blood pressure reduction to 185/110 mmHg or lower should be considered in people who are candidates for thrombolysis

Blood pressure control for people with acute intracerebral haemorrhage

• rapid blood pressure lowering treatment should be offered to people with acute intracerebral haemorrhage who do not have any of the exclusions listed* and who:
  • present within 6 hours of symptom onset and
  • have a systolic blood pressure between 150 and 220 mmHg
  • aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days
• consider rapid blood pressure lowering for people with acute intracerebral haemorrhage who do not have any of the exclusions listed * and who:
  • present beyond 6 hours of symptom onset or
  • have a systolic blood pressure greater than 220mmHg
  • aim for a systolic blood pressure target of 130 to 140 mmHg within 1 hour of starting treatment and maintain this blood pressure for at least 7 days

* do not offer rapid blood pressure lowering to people who:

• have an underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)
• have a score on the Glasgow Coma Scale of below 6
• are going to have early neurosurgery to evacuate the haematoma
• have a massive haematoma with a poor expected prognosis

Notes:

• there is no definitive evidence as to whether antihypertensive drugs should be started immediately after an ischaemic stroke or if current medication should be continued in the acute post-ictal phase
  • in a study investigating the treatment of hypertension post stroke (patients over 18 years admitted to hospital with a clinical diagnosis of suspected stroke and symptom onset < 36 hours and hypertension, defined as systolic BP (SBP) < 160 mmHg) (2)
    • oral and sublingual lisinopril and oral and intravenous labetalol were effective BP-lowering agents in acute cerebral infarction and haemorrhage and did not increase the likelihood of early neurological deterioration
      • study was not sufficiently powered to detect a difference in disability or death at 2 weeks
• an analysis (4 RCTs; n=1,571) after thrombectomy in acute stroke, found no significant differences between intensive and standard BP control in this patient for 90-day mortality (RR 1.18; 95% CI 0.92-1.52), symptomatic intracranial haemorrhage (1.12; 0.75-1.67), or hypotensive events (1.80; 0.37-8.76)

References:

1. NICE. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline NG128. Published May 2019, last updated April 2022
2. Poter JF et al. Controlling hypertension and hypotension immediately post stroke (CHHIPS)--a randomised controlled trial. Lancet Neurol 2009;8:48-56.
3. Ghozy S et al. Intensive vs Conventional Blood Pressure Control After Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2024 Feb 5;7(2):e240179