Hypertension treatment thresholds post stroke

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)

Reference:

• (1) NICE (May 2019). The diagnosis and acute management of stroke and transient ischaemic attacks
• (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, Mortezaei A, Elfil M, Abdelghaffar M, Kobeissi H, Aladawi M, Abbas AS, Nayak SS, Kadirvel R, Rabinstein AA, Kallmes DF. 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