Treatment of Hypertension in Acute Stroke

The consultant in charge of the patient should be notified in each case

before a patient with an acute stroke has their blood pressure
actively lowered
Principle & background
Early (30 day) mortality is about 10% in cerebral infarction:
o Risk is greatest if Systolic BP 130mm!g and"or #iastolic BP
$0mm!g
Early (30 day) mortality is about %0% in intracerebral &emorr&age
o Risk is greatest if Systolic BP ' 1(0mm!g and"or #iastolic BP '
1%0mm!g
)&ese are only associations and in most cases lo*ering t&e BP *ill +otentially
e,tend t&e stroke area and *orsen t&e +atient-s condition. BP generally returns to
baseline o/er 012$% &ours.
WHEN TO TREAT t!ese are opinion based recommendations as proper
e"idence for ideal treatment does not e#ist at t!is time
$sc!aemic Stroke
1. 3o t&rombolysis +lanned 4 treat if SBP 5%%0 6"2 #BP 51%0 mm!g
%. 7f t&rombolysis +lanned 4 treat if SBP 51(0 6"2 #BP 5110 mm!g
8im: 9o*er BP by 1021:% only
$ntracerebral Haemorr!age
1. #iscuss *it& consultant *&et&er intracerebral +ressure (7;P) monitoring is
+lanned
if so< aim for cerebral +erfusion +ressure (;PP) (=>8P 4 7;P) 5 ?0
mm!g
%. 7f 7;P monitoring not +lanned
aim for SBP 1:021?0 mm!g and >8P 11021%0 mm!g
(>8P = 1"3 SBP 6 %"3 #BP)
Subarac!noid Haemorr!age %SAH&
7f +atient alert (;PP is likely to be normal)
lo*er SBP to around 100 mm!g
7f unconscious 4 do 3@) lo*er BP in 1
st
0&rs
HOW TO TREAT
BP in t&is setting is ty+ically labile and intra/enous treatment as
belo* is more likely to ac&ie/e smoot& BP control t&an oral
medications as absor+tion and action are less +redictable.
HYDRALAZINE
1. Begin with bolus doses 5mg ivi 20-30 minutes apart to a maximum
of 3 doses.
If BP rises again despite this then use infusion as below
2. !"drala#ine infusion $%0 mg in 500 m& '(saline) * 1-5 mg(hr $+-
30 ml(hr)
Side effects: Alus&ing< tac&ycardia< &eadac&e
METOPROLOL
#ose: : mg bolus gi/en o/er %23 mins
Re+eat at : minute inter/als u+ to ma,imum %0 mg
>onitor *it& E;B during treatment
Ensure no contraindications to C2blockers
E,creted renally so *atc& for bradycardia in +atients *it& renal failure.
Sodium 3itro+russide is also an e,cellent drug to use in t&is setting if a++ro+riate
monitoring is a/ailable ( see table of nitro+russide use in D)reatment of
&y+ertensi/e emergency-)
Note: when withdrawing hydralazine, metoprolol or nitroprusside this should be
done by reducing the infusion rate or bolus schedule slowly over hours and
overlapping with oral antihypertensives
Selected references:
;astillo et al. Stroke. %000E3:::%02?
@li/eira2Ail&o et al. 3eurology. %003E?1:103021
Fillmot et al.!y+ertension.%000E03:112%0
@kumura et al. G !y+ertension. %00:E%3:1%1$2%3
H+)o#ate online