NEUROLOGY/EXPERT CLINICAL MANAGEMENT
Managing Hypertension in Patients With
Acute Stroke
Michael N. Cocchi, MD*; Jonathan A. Edlow, MD
*Corresponding Author. E-mail: mcocchi@bidmc.harvard.edu, Twitter: @MichaelCocchiMD.
0196-0644/$-see front matter
Copyright © 2019 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2019.09.015
[Ann Emerg Med. 2019;-:1-5.]
INTRODUCTION
For patients presenting to the emergency department
(ED) with acute stroke, treatments in the minutes to hours
after the event can affect outcomes. Patients with acute
stroke often present with elevated blood pressure, which
can exacerbate the underlying pathology and drive
therapeutic interventions. This article focuses on the
current evidence-based approach to blood pressure
management in the setting of acute stroke, including acute
ischemic stroke, aneurysmal subarachnoid hemorrhage, and
intraparenchymal hemorrhage. When direct evidence is
lacking, we suggest approaches based on what data do exist,
pathophysiologic principles, and our own practice. Table 1
provides a concise summary of existing recommendations
and targets based on cause.
GENERAL PRINCIPLES
Elevated blood pressure in the setting of acute stroke is
common. In one national data set of greater than 500,000
patients presenting to the ED with stroke, nearly 60% had
elevated blood pressure.1 Another systematic review of 18
studies found that 52% of patients with acute stroke were
hypertensive at admission.2
Acute blood pressure management in the setting of
acute intracranial pathology centers around the principle
of optimizing cerebral perfusion pressure, which can be
affected by both the mean arterial blood pressure and the
intracranial pressure, as represented by the following
formula: cerebral perfusion pressure¼mean arterial blood
pressure–intracranial pressure. As the intracranial
pressure increases, the mean arterial blood pressure must
be maintained at a level that ensures adequate cerebral
perfusion pressure. Autoregulation is the physiologic
process by which blood flow in a given circulation (in
this case, cerebral) is maintained over a wide range of
systemic blood pressure. When autoregulation is intact,
Volume -, no. - : - 2019
cerebral blood flow is maintained in a normal range
through vasoconstriction and vasodilation of intracranial
vessels. Because the majority of these patients will not
have intracranial pressure monitoring, judgments about
elevated intracranial pressure are based on clinical (eg,
headache, confusion, vomiting, diplopia) or imaging
(obliteration of normal cerebral spinal fluid-filled spaces
on computed tomography or optic nerve sheath diameter
by ultrasonography) findings.
Cerebral perfusion pressure can be manipulated by
either decreasing intracranial pressure or increasing mean
arterial blood pressure. Elevating the head of the bed to at
least 30 degrees is appropriate in most cases when the
intracranial pressure is elevated. Given available data and
guidelines,3,4 in most cases it is reasonable to maintain the
head elevated at 30 degrees, but individual circumstances
may be relevant. For example, a patient with acute ischemic
stroke and a flow-limiting stenosis may benefit from flat
positioning, whereas an intracerebral hemorrhage patient
with known elevated intracranial pressure will need head-
of-bed elevation. Care should also be taken to avoid
reductions in venous return from the head (tight cervical
collars or central line dressings) that could elevate
intracranial pressure.
In regard to manipulations of mean arterial blood
pressure, use of short-acting intravenous agents to manage
blood pressure and continuous infusions that can be
carefully titrated may be advantageous in the acute setting
(Table 2).
Acute Ischemic Stroke
The optimal blood pressure management strategy in
acute ischemic stroke remains controversial, in part because
of a lack of clear evidence based on randomized controlled
trial data. Balancing preservation of perfusion to the
cerebral ischemic (but not yet infarcted) penumbra to avoid
extension of the infarct with the risk of hemorrhagic
conversion is the goal, both of which can result in worsened
neurologic outcomes.
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Managing Hypertension in Patients With Acute Stroke Cocchi & Edlow

Table 1. Guideline-recommended blood pressure targets.

Stroke Type Target, mm Hg Notes
Acute ischemic stroke
IV tPA eligible5 <185/110
During/after tPA 5
<180/105 AHA/ASA recommendations are to monitor BP every 15 min for 2 h, then every 30 min
for 6 h, and then hourly until 24 h.
No tPA5 <220/120
Mechanical BP 180/105 Maintain this range during and for 24 h after the procedure.
thrombectomy5
Aneurysmal subarachnoid
hemorrhage
Unsecured15 SBP <160 Some experts advocate <140 mm Hg; other recommendations include mean arterial
blood pressure <110 mm Hg, SBP <160 mm Hg,16 or both, or SBP target of <180
mm Hg.17
Secured Unclear May depend on patient-specific factors such as premorbid blood pressure and
presence of vasospasm.
Intraparenchymal
hemorrhage
Initial SBP 150 to 220 Aim for SBP <140 mm Hg
mm Hg21
Initial SBP >220 mm Aim for SBP 140–160 mm Hg
Hg21

IV, Intravenous; BP, blood pressure; SBP, systolic blood pressure.

For acute ischemic stroke, blood pressure targets will be first 24 hours after acute ischemic stroke.5 The data on
determined by whether the patient is eligible for treatment which the recommendation is made are limited because
with systemic thrombolysis. For acute ischemic stroke these patients have been excluded from clinical trials
patients not undergoing intravenous alteplase or evaluating blood pressure lowering after acute ischemic
endovascular therapy, there is a 2018 Class IIb American stroke, so clinical judgment will be necessary, and
Heart Association (AHA)/American Stroke Association treatment should be individualized. In patients with various
(ASA) position that states that it is reasonable for patients comorbid conditions, such as acute coronary syndrome or
with blood pressure greater than 220/120 mm Hg to heart failure, the decisionmaking involved in blood pressure
experience a decrease in blood pressure of 15% within the management may be driven by these other conditions.
Table 2. Commonly used medications for blood pressure management in acute stroke.
Agent Typical Dose/Range Notes Cautions/Contraindications
Labetalol 10–20 mg IV during 1–2 min; may Onset of action 5 min Avoid use in COPD, asthma, heart failure,
repeat 1 time bradycardia, heart block
Nicardipine IV infusion at 5 mg/h; titrate up by Onset of action 1–5 Avoid in severe aortic stenosis
2.5 mg/h every 5–15 min; min
maximum 15 mg/h
Clevidipine 1–2 mg/h IV; titrate by doubling the Onset of action 2–4 Do not use in patients with egg/soy allergy
dose every 2–5 min until desired min; short half-life because of lipid emulsion carrier
BP reached; maximum 21 mg/h Avoid in severe aortic stenosis
Hydralazine 10–20 mg IV; repeat every 4–6 h Onset of action 10– Can cause reflex tachycardia
20 min
Other agents (eg,
enalaprilat, esmolol)
may also be considered

COPD, Chronic obstructive pulmonary disease.

2 Annals of Emergency Medicine Volume -, no. - : - 2019

Cocchi & Edlow
Current AHA/ASA guidelines suggest that decreasing the
blood pressure by 15% in these scenarios is probably safe
(Class I). It is important to understand that overtreatment
(decreasing the blood pressure too much) risks worsening
cerebral ischemia,6 and this should be considered when
medications are titrated. In the China Antihypertensive
Trial in Acute Stroke, 4,071 patients who presented within
48 hours of onset of an acute ischemic stroke, with an
elevated blood pressure between 140 and 220 mm Hg,
were randomized to either antihypertensive treatment
(decreasing by 10% to 25% within the first 24 hours after
randomization to achieve less than 140/90 mm Hg within
7 days and maintaining that throughout the
hospitalization) or the control arm (not receiving
antihypertensive treatment, including discontinuation of
home antihypertensive medications). There was no
significant difference in primary outcome composite
measure of death or major disability at day 14 or hospital
discharge between groups.7
For patients who are potentially eligible for treatment
with intravenous alteplase, the systolic blood pressure
should be maintained at less than 185 mm Hg and the
diastolic blood pressure at less than 110 mm Hg (Class I
ASA/AHA recommendation). During or after infusion of
a thrombolytic agent, the recommendation is to maintain
blood pressure at less than 180/105 mm Hg. The exact
blood pressure at which the risk of hemorrhage increases
in the setting of systemic thrombolysis is currently
unknown and may differ from patient to patient. In the
absence of new and more compelling data, it is
reasonable to use the blood pressure parameters used in
the original trials.5
For patients who are undergoing mechanical
thrombectomy, there are very limited data about the
optimal blood pressure targets during and after the
procedure; there is a new Class IIa recommendation for
maintaining the blood pressure at less than or equal to 180/
105 mm Hg during and for 24 hours after the procedure.5
In the Randomized Assessment of Rapid Endovascular
Treatment of Ischemic Stroke trial, patients with a
proximal intracranial occlusion in the anterior circulation
up to 12 hours after onset were randomized to standard
care alone versus standard care plus endovascular therapy
(mechanical thrombectomy); that protocol advised
maintaining systolic blood pressure at greater than 150 mm
Hg to maintain flow through collateral vessels, and then in
the postprocedure period aiming for a target that would be
considered normal for the individual patient.8 The
Diffusion-Weighted Imaging or Computerized
Tomography Perfusion Assessment With Clinical
Mismatch in the Triage of Wake-up and Late Presenting
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Managing Hypertension in Patients With Acute Stroke
Strokes Undergoing Neurointervention With Trevo trial,
which randomized patients with an occlusion of the
intracranial internal carotid artery, the first segment of the
middle cerebral artery, or both, and mismatch between
clinical deficit severity and infarct volume, to
thrombectomy plus standard care versus standard care
alone, recommended maintaining systolic blood pressure at
less than 140 mm Hg in the first 24 hours after reperfusion
from mechanical thrombectomy.9
There are no data to favor one agent over another for
decreasing blood pressure after acute ischemic stroke.
The most common choices are titratable infusions such
as nicardipine or clevidipine, but bolus dosing of agents
such as labetalol is also reasonable (Table 2). Although
not specific to stroke, a 2011 multicenter randomized
controlled trial compared use of nicardipine infusion
versus labetalol bolus dosing for undifferentiated
hypertensive emergency in 226 patients and found that
patients who received nicardipine were 2.7 times more
likely to be in target blood pressure range within 30
minutes compared with those treated with labetalol. In
this trial, overshooting of blood pressure targets was less
than 15% with either medication, and no evidence of
significant harm was found with either agent.10 In the
absence of compelling evidence of superiority, clinicians
may need to consider resources available, as well as other
patient-specific parameters such as pulse rate, when
deciding on the agent to use. In most cases, we generally
prefer nicardipine or clevidipine for blood pressure
management when necessary in acute ischemic stroke,
given the ease of titration with these agents.
Aneurysmal Subarachnoid Hemorrhage
The most feared complication of an aneurysmal
subarachnoid hemorrhage is rebleeding, which may have an
incidence of up to 15% within the first 24 hours and carries
with it significant morbidity and mortality, with a fatality
rate as high as 70% described.11-13 Despite recognition of
risk of this complication, evidence supporting a specific
blood pressure management strategy that can reduce this
danger is limited, and there remains large variability in
blood pressure targets used in this subset of intracerebral
hemorrhage. In one survey study of 128 clinicians (mostly
neurointensivists), systolic blood pressure targets ranged
from 140 to 180 mm Hg before aneurysm securement and
160 to 240 mm Hg postsecurement.14 The current AHA/
ASA guidelines suggest a target of systolic blood pressure
less than 160 mm Hg before aneurysm securement (Class
IIa, Level of Evidence C),15 whereas the Neurocritical Care
Society consensus recommendations endorsed a target of
Annals of Emergency Medicine 3
Managing Hypertension in Patients With Acute Stroke
mean arterial blood pressure less than 110 mm Hg, systolic
blood pressure less than 160 mm Hg, or both.16 European
guidelines have been more liberal, with a systolic blood
pressure target of less than 180 mm Hg.17
Given the paucity of data for specific targets, there is
even less guidance on specific agents to achieve blood
pressure control in this population. As with patients with
acute ischemic stroke, use of easily titratable agents may be
preferred, and we generally prefer nicardipine or
clevidipine.
Intracerebral Hemorrhage
For patients presenting with an intracerebral
hemorrhage not related to an aneurysm or other vascular
malformation, the focus is on blood pressure management,
with a concern for worsening the hemorrhage, although the
evidence for particular targets is limited. Hematoma growth
is a predictor of morbidity and mortality after intracerebral
hemorrhage, and elevated blood pressure in this context has
been associated with hematoma enlargement.18-20
The majority of these patients will not have intracranial
pressure monitoring devices, and therefore accounting for
elevations in intracranial pressure must be made on clinical
and neuroimaging factors. In accordance with the most up-
to-date 2015 guidelines from the AHA/ASA, for patients
who present with a systolic blood pressure 150 to 220 mm
Hg without a clear contraindication for acute blood pressure
treatment, immediate reduction to 140 mm Hg is likely safe
(Class I; LOE A) and may improve functional outcome
(Class IIa; LOE B). For patients with systolic blood pressure
greater than 220 mm Hg, reduction in the blood pressure
with a titratable infusion and frequent blood pressure
monitoring is recommended, with a target of systolic blood
pressure 140 to 160 mm Hg (Class IIb; LOE C).21
Data from recent trials support these recommendations.
The Intensive Blood Pressure Reduction in Acute Cerebral
Hemorrhage trial, a randomized pilot study of 204 patients
who presented with intracerebral hemorrhage,
demonstrated that rapid reduction to a target of systolic
blood pressure 140 mm Hg within 6 hours was safe.22 In
this trial, the authors also found that there was a reduction
in hematoma growth in the intensive target group,
although this did not achieve statistical significance. The
follow-up trial randomized 2,839 patients with acute
intracerebral hemorrhage and elevated blood pressure to
either intensive blood pressure management (systolic blood
pressure 140 mm Hg within 1 hour) or more standard
blood pressure management (systolic blood pressure 180
mm Hg) and found no difference in mortality, severe
disability, or adverse events. In a secondary analysis, the
4 Annals of Emergency Medicine
Cocchi & Edlow
authors identified improvement in functional outcomes as
measured by modified Rankin Scale scores in the more
intensive control group.23 The Antihypertensive Treatment
of Acute Cerebral Hemorrhage II trial was a randomized
controlled trial of 1,000 patients presenting with
intracerebral hemorrhage that compared an intensive blood
pressure range of systolic blood pressure 110 to 139 mm
Hg with a more standard-care range of systolic blood
pressure 140 to 179 mm Hg; this trial was stopped early for
futility according to a prespecified interim analysis that
demonstrated no difference in mortality or disability
between the groups. There were more renal adverse events
noted in the intensive treatment group.24
Guidelines offer a data-driven framework to make
decisions, but by necessity, they suggest general approaches
to individual patients. Target blood pressure goals should
be tailored to individual patients, accounting for baseline
premorbid blood pressure levels, the likelihood of elevated
intracranial pressure, and comorbid conditions. When
appropriate, intracranial pressure monitoring allows
clinicians to more rationally decide on a target blood
pressure for the individual patient.
VASOACTIVE MEDICATIONS
Choice of agent used to manage blood pressure in the
acute stroke setting may be based on patient-specific
factors, and clinical judgment in the overall context of the
patient scenario is important. Using a titratable infusion
such as nicardipine or clevidipine may be preferable to a
bolus-dosing agent to more carefully achieve the desired
response. In a small (n¼54) pseudorandomized trial of
nicardipine versus labetalol, patients who received
nicardipine had more effective blood pressure management
and demonstrated a more reliable dose response.25
Clevidipine, which is notable for its rapid onset of action
and short half-life, has demonstrated efficacy in achieving
target blood pressure in spontaneous intracerebral
hemorrhage.26 In general, nitroprusside is avoided in
neurocritically ill patients because of its potential to
increase intracranial pressure.27 Regardless of the agent
used, it is important to monitor the response closely and
avoid inadvertent hypotension.
SUMMARY
Optimal blood pressure targets in the setting of acute
ischemic stroke, acute subarachnoid hemorrhage, and
spontaneous intracerebral hemorrhage remain somewhat
controversial, and the evidence is evolving. Guidelines offer
a data-driven framework to make decisions, but by
necessity, they suggest general approaches to individual
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Cocchi & Edlow
patients. Target blood pressure goals should be informed by
existing evidence-based guidelines but tailored to individual
patients.
Supervising editor: Steven M. Green, MD. Specific detailed
information about possible conflict of interest for individual editors
is available at https://www.annemergmed.com/editors.
Author affiliations: From the Department of Emergency Medicine
(Cocchi, Edlow) and Department of Anesthesia Critical Care,
Division of Critical Care (Cocchi), Beth Israel Deaconess Medical
Center, Boston, MA.
Authorship: All authors attest to meeting the four ICMJE.org
authorship criteria: (1) Substantial contributions to the conception
or design of the work; or the acquisition, analysis, or interpretation
of data for the work; AND (2) Drafting the work or revising it
critically for important intellectual content; AND (3) Final approval
of the version to be published; AND (4) Agreement to be
accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE conflict
of interest guidelines (see www.icmje.org). The authors have stated
that no such relationships exist.
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Annals of Emergency Medicine 5