Updated: May 7
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.
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 .
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 . 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 .
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 . 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 .
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.
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