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Blood Pressure Targets in Acute Stroke

Updated: May 7, 2023


Blood pressure management plays a crucial role in the treatment of acute intracerebral hemorrhage (ICH) and ischemic stroke. While several clinical trials have focused on lowering blood pressure in patients with ICH, the relationship between blood pressure and clinical outcomes in acute ischemic stroke is much more complicated due to the utilization of intravenous thrombolytic therapy and arterial mechanical thrombectomy. In this article, we review the results of clinical trials and guidelines related to blood pressure management in ICH and ischemic stroke, including target blood pressure ranges and the use of blood pressure-lowering agents before and after thrombolysis or thrombectomy. Understanding the intricacies of blood pressure management in these stroke subtypes is critical for optimizing patient outcomes and reducing the risk of complications.


What is the systolic blood pressure target in intracranial hemorrhage?

  • 0%110-130 mm Hg

  • 0%130-139 mm Hg

  • 0%140-160 mm Hg


Intracerebral Hemorrhage (ICH)

Several clinical trials focused on lowering blood pressure in patients with intracerebral hemorrhage. The INTERACT-1 trial showed that intensive blood pressure lowering treatment (target systolic blood pressure 140 mm Hg) was feasible and well-tolerated, and this formed the basis for the INTERACT-2 trial, which aimed to improve functional outcomes. While the intensive treatment did not result in a significant reduction in mortality and disability, it did lead to improved functional outcomes. The ATACH-2 trial administered a standardized blood pressure lowering regimen but was stopped early due to futility, and the primary outcome was not different between the intensive and standard treatment groups. Lastly, a trial conducted in India compared tight blood pressure control with conventional control and found no significant difference in the primary outcome measured as modified Rankin Scale at 90 days [1-4].


Lowering blood pressure intensively seems advantageous for patients with a wide range of baseline systolic blood pressure levels, and a target SBP range of 130-139 mm Hg is thought to be the most beneficial in cases of acute intracerebral hemorrhage. The American Heart Association (AHA) and the American Stroke Association (ASA) suggest that for patients with ICH and a SBP between 150-220 mm Hg, and without any contraindications to acute blood pressure treatment, lowering the SBP to 140 mm Hg is advisable [5].

Acute Ischemic Stroke

In patients with acute ischemia, the relationship between blood pressure and clinical outcomes is much more complicated compared to ICH. The intricacy of managing blood pressure in acute ischemic stroke primarily stems from the utilization of intravenous thrombolytic therapy and arterial mechanical thrombectomy.


Observational studies have shown that there is a J- or U-shaped relationship between blood pressure and clinical outcomes in patients with acute ischemic stroke without revascularization, with both high and low blood pressures being associated with unfavorable outcomes. The nadir for blood pressure varies between studies, ranging from 120 to 185 mm Hg of systolic blood pressure, but mostly around 150-160 mm Hg.


Clinical trials involving patients with acute ischemic stroke have varying recruitment criteria, such as differences in the time interval after stroke onset or the use of arterial mechanical thrombectomy. The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) found no difference in death and disability between the antihypertensive treatment and non-treatment control group, while the ENCHANTED trial found no difference in functional status between the intensive and guideline-based treatment groups [6-7]. MAPAS trial compared three different blood pressure groups and found that the odds of having good outcome was greater in SBP 161-180 mmHg and ICB occurred more frequently in group with SBP target of 181-200 mmHg). The BP-TARGET trial found no significant difference in the rate of radiographic intraparenchymal hemorrhage between the intensive and standard treatment groups [8-9].


According to the 2018 AHA/ASA guidelines, patients with ischemic stroke and elevated blood pressure who are eligible for treatment with intravenous alteplase should maintain a SBP and diastolic blood pressure (DBP) below 185/110 mm Hg before receiving fibrinolytic therapy [10]. The 2018 Canadian guidelines also recommend a pre-treatment blood pressure target of <185/110 mm Hg for alteplase therapy, as well as a post-treatment target of <180/105 mm Hg for the following 24 hours. For patients undergoing arterial mechanical thrombectomy without prior intravenous thrombolytic therapy, it is reasonable to maintain a blood pressure of ≤185/110 mm Hg before the procedure [11].


In cases where patients have a SBP/DBP <220/110 mm Hg and have not undergone intravenous thrombolysis or mechanical thrombectomy, the routine use of blood pressure-lowering agents in the first 24 hours following symptom onset is not recommended, unless necessary for the management of a specific comorbid condition, as per the 2021 European Stroke Organization guidelines [12]. If blood pressure is above 220/110 mm Hg, a reduction of approximately 15% (but no more than 25%) over the first 24 hours is suggested, with gradual reduction thereafter to reach long-term secondary stroke prevention targets as per the 2018 Canadian guidelines [11].


Blood Pressure Targets in Acute Stroke

Summary

In summary, blood pressure management is crucial in both intracerebral hemorrhage and acute ischemic stroke. To optimize patient outcomes, intensivists should aim to keep systolic blood pressure in intracranial hemorrhage below 140 mm Hg. In acute ischemic stroke, treatment is recommended for blood pressure above 220/110 if no intervention of thrombolytics is planned. For patients eligible for intravenous alteplase therapy, maintaining a goal of <185/110 prior to thrombolytic therapy and below 180/105 after thrombolytic therapy or in cases of thrombectomy is recommended by guidelines. By following these guidelines, intensivists can provide the best possible care for patients with intracerebral hemorrhage and ischemic stroke.



REFERENCES

  1. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, Heeley E, Skulina C, Parsons MW, Kim JS, Tao QL, Li YC, Jiang JD, Tai LW, Zhang JL, Xu E, Cheng Y, Heritier S, Morgenstern LB, Chalmers J. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol 2008; 7:391–399. [PubMed] [Google Scholar]

  2. 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. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368:2355–2365. [PubMed] [Google Scholar]

  3. 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. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375:1033–1043. [PMC free article] [PubMed] [Google Scholar]

  4. Gupta S, Abbot AK, Srinath R, Tewari AK, Gupta A, Gorthi SP, Narayanan CS, Totlani SI, Sirohi YS, Anadure R. Randomized trial to assess safety and clinical efficacy of intensive blood pressure reduction in acute spontaneous intracerebral haemorrhage. Med J Armed Forces India 2018; 74:120–125. [PMC free article] [PubMed] [Google Scholar]

  5. 23. Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, MacDonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46:2032–2060. [PubMed] [Google Scholar]

  6. 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, Wang X, Cui Y, Li Y, Ma D, Yang G, Gao Y, Yuan X, Bazzano LA, Chen J. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA 2014; 311:479–489. [PubMed] [Google Scholar]

  7. Anderson CS, Huang Y, Lindley RI, Chen X, Arima H, Chen G, Li Q, Billot L, Delcourt C, Bath PM, Broderick JP, Demchuk AM, Donnan GA, Durham AC, Lavados PM, Lee TH, Levi C, Martins SO, Olavarria VV, Pandian JD, Parsons MW, Pontes-Neto OM, Ricci S, Sato S, Sharma VK, Silva F, Song L, Thang NH, Wardlaw JM, Wang JG, Wang X, Woodward M, Chalmers J, Robinson TG. 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; 393:877–888. [PubMed] [Google Scholar]

  8. Nasi LA, Martins SCO, Gus M, Weiss G, de Almeida AG, Brondani R, Rebello LC, DalPizzol A, Fuchs FD, Valença MJM, Wirth LF, Nunes G, Anderson CS. Early manipulation of arterial blood pressure in acute ischemic stroke (MAPAS): Results of a randomized controlled trial. Neurocrit Care 2019; 30:372–379. [PubMed] [Google Scholar]

  9. Mazighi M, Richard S, Lapergue B, Sibon I, Gory B, Berge J, Consoli A, Labreuche J, Olivot JM, Broderick J, Duhamel A, Touze E, Qureshi AI, Yavchitz A, Escalard S, Desilles JP, Redjem H, Smajda S, Fahed R, Hébert S, Maïer B, Delvoye F, Boursin P, Maacha MB, Obadia M, Sabben C, Blanc R, Savatovsky J, Piotin M. Safety and efficacy of intensive blood pressure lowering after successful endovascular therapy in acute ischaemic stroke (BP-TARGET): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2021; 20:265–274. [PubMed] [Google Scholar]

  10. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early 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:e344–e418. [PubMed] [Google Scholar]

  11. Boulanger JM, Lindsay MP, Gubitz G, Smith EE, Stotts G, Foley N, Bhogal S, Boyle K, Braun L, Goddard T, Heran M, Kanya-Forster N, Lang E, Lavoie P, McClelland M, O’Kelly C, Pageau P, Pettersen J, Purvis H, Shamy M, Tampieri D, vanAdel B, Verbeek R, Blacquiere D, Casaubon L, Ferguson D, Hegedus Y, Jacquin GJ, Kelly M, Kamal N, Linkewich B, Lum C, Mann B, Milot G, Newcommon N, Poirier P, Simpkin W, Snieder E, Trivedi A, Whelan R, Eustace M, Smitko E, Butcher K. Canadian stroke best practice recommendations for acute stroke management: prehospital, emergency department, and acute inpatient stroke care, 6th Edition, Update 2018. Int J Stroke 2018; 13:949–984. [PubMed] [Google Scholar]

  12. Sandset EC, Anderson CS, Bath PM, Christensen H, Fischer U, GÄ…secki D, Lal A, Manning LS, Sacco S, Steiner T, Tsivgoulis G. European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage. Eur Stroke J 2021; 6:II. [PMC free article] [PubMed] [Google Scholar]Retracted



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