J Neurocrit Care.  2020 Dec;13(2):69-79. 10.18700/jnc.200028.

Blood pressure management in stroke patients

• Kim SM
• Woo HG
• Kim YJ
• Kim BJ

• KMID: 2509935
• DOI: http://doi.org/10.18700/jnc.200028

Abstract

Hypertension is a major, yet manageable, risk factor for stroke, and the benefits of well-controlled blood pressure are well established. However, the strategy for managing blood pressure can differ based on the pathomechanism (subtype), stage, and treatment of stroke patients. In the present review, we focused on the management of blood pressure during the acute stage of intracerebral hemorrhage, subarachnoid hemorrhage, and cerebral infarction. In patients with cerebral infarction, the target blood pressure was discussed both before and after thrombolysis or other endovascular treatment, which may be an important issue. When and how to start antihypertensive medications during the acute ischemic stroke period were also discussed. In regards to the secondary prevention of ischemic stroke, the target blood pressure may differ based on the mechanism of ischemic stroke. We have reviewed previous studies and guidelines to summarize blood pressure management in various situations involving stroke patients.

Keyword

Stroke; Hypertension; Cerebral infarction; Intracranial hemorrhage

Figure

• 

  Fig. 1. Blood pressure (BP) management according to treatment of ischemic stroke; (A) intravenous thrombolysis (IV tPA), (B) endovascular treatment, and (C) not indicated for reperfusion therapy and secondary stroke prevention. SBP, systolic blood pressure; ESCAPE, endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing computed tomography (CT) to recanalization times; DAWN, diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention.

• 

  Fig. 2. Pathophysiology and blood pressure target according to ischemic stroke mechanisms. SBP, systolic blood pressure; WASID, Warfarin Aspirin Symptomatic Intracranial Disease; STABLE-ICAS, strategy for adequate blood pressure lowering in the patients with intracranial atherosclerosis.

Reference

1. Ziai WC, Gusdon AM, Hanley DF. Blood pressure in intracerebral haemorrhage: which variables matter? Lancet Neurol. 2019; 18:810–2.

2. Wijdicks EF, Vermeulen M, Murray GD, Hijdra A, van Gijn J. The effects of treating hypertension following aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg. 1990; 92:111–7.

3. Kim BJ, Kim JS. Ischemic stroke subtype classification: an asian viewpoint. J Stroke. 2014; 16:8–17.

4. Hong KS, Bang OY, Kim JS, Heo JH, Yu KH, Bae HJ, et al. Stroke statistics in Korea: part II stroke awareness and acute stroke care, a report from the Korean stroke society and clinical research center for stroke. J Stroke. 2013; 15:67–77.

5. Alexander RW. Hypertension and the pathogenesis of atherosclerosis. Oxidative stress and the mediation of arterial inflammatory response: a new perspective. Hypertension. 1995; 25:155–61.

6. Verdecchia P, Angeli F, Reboldi G. Hypertension and atrial fibrillation: doubts and certainties from basic and clinical studies. Circ Res. 2018; 122:352–68.

7. SPS3 Study Group, Benavente OR, Coffey CS, Conwit R, Hart RG, McClure LA, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013; 382:507–15.

8. An SJ, Kim TJ, Yoon BW. Epidemiology, risk factors, and clinical features of intracerebral hemorrhage: an update. J Stroke. 2017; 19:3–10.

9. Tikhonoff V, Zhang H, Richart T, Staessen JA. Blood pressure as a prognostic factor after acute stroke. Lancet Neurol. 2009; 8:938–48.

10. Qureshi AI, Ezzeddine MA, Nasar A, Suri MF, Kirmani JF, Hussein HM, et al. Prevalence of elevated blood pressure in 563,704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007; 25:32–8.

11. Rodriguez-Luna D, Piñeiro S, Rubiera M, Ribo M, Coscojuela P, Pagola J, et al. Impact of blood pressure changes and course on hematoma growth in acute intracerebral hemorrhage. Eur J Neurol. 2013; 20:1277–83.

12. Butcher KS, Jeerakathil T, Hill M, Demchuk AM, Dowlatshahi D, Coutts SB, et al. The intracerebral hemorrhage acutely decreasing arterial pressure trial. Stroke. 2013; 44:620–6.

13. Anderson CS, Heeley E, Huang Y, Wang J, Stapf C, Delcourt C, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355–65.

14. Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016; 375:1033–43.

15. Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015; 46:2032–60.

16. Buletko AB, Thacker T, Cho SM, Mathew J, Thompson NR, Organek N, et al. Cerebral ischemia and deterioration with lower blood pressure target in intracerebral hemorrhage. Neurology. 2018; 91:e1058–66.

17. Arima H, Heeley E, Delcourt C, Hirakawa Y, Wang X, Woodward M, et al. Optimal achieved blood pressure in acute intracerebral hemorrhage: INTERACT2. Neurology. 2015; 84:464–71.

18. Chung PW, Kim JT, Sanossian N, Starkmann S, Hamilton S, Gornbein J, et al. Association between hyperacute stage blood pressure variability and outcome in patients with spontaneous intracerebral hemorrhage. Stroke. 2018; 49:348–54.

19. Divani AA, Liu X, Di Napoli M, Lattanzi S, Ziai W, James ML, et al. Blood pressure variability predicts poor in-hospital outcome in spontaneous intracerebral hemorrhage. Stroke. 2019; 50:2023–9.

20. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012; 43:1711–37.

21. Diringer MN, Bleck TP, Claude Hemphill J 3rd, Menon D, Shutter L, Vespa P, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care. 2011; 15:211–40.

22. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013; 35:93–112.

23. Lin QS, Ping-Chen , Lin YX, Lin ZY, Yu LH, Dai LS, et al. Systolic blood pressure variability is a novel risk factor for rebleeding in acute subarachnoid hemorrhage: a case-control study. Medicine (Baltimore). 2016; 95:e3028.

24. Yang M, Pan X, Liang Z, Huang X, Duan M, Cai H, et al. Association between blood pressure variability and the short-term outcome in patients with acute spontaneous subarachnoid hemorrhage. Hypertens Res. 2019; 42:1701–7.

25. Naidech AM, Jovanovic B, Wartenberg KE, Parra A, Ostapkovich N, Connolly ES, et al. Higher hemoglobin is associated with improved outcome after subarachnoid hemorrhage. Crit Care Med. 2007; 35:2383–9.

26. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018; 49:e46–110.

27. Anderson CS, Huang Y, Lindley RI, Chen X, Arima H, Chen G, et al. 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; 393:877–88.

28. Delgado-Mederos R, Ribo M, Rovira A, Rubiera M, Munuera J, Santamarina E, et al. Prognostic significance of blood pressure variability after thrombolysis in acute stroke. Neurology. 2008; 71:552–8.

29. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015; 372:1019–30.

30. Jovin TG, Saver JL, Ribo M, Pereira V, Furlan A, Bonafe A, et al. Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods. Int J Stroke. 2017; 12:641–52.

31. Anadani M, Orabi MY, Alawieh A, Goyal N, Alexandrov AV, Petersen N, et al. Blood pressure and outcome after mechanical thrombectomy with successful revascularization. Stroke. 2019; 50:2448–54.

32. Anadani M, Arthur AS, Tsivgoulis G, Simpson KN, Alawieh A, Orabi Y, et al. Blood pressure goals and clinical outcomes after successful endovascular therapy: a multicenter study. Ann Neurol. 2020; 87:830–9.

33. Rasmussen M, Schönenberger S, Hendèn PL, Valentin JB, Espelund US, Sørensen LH, et al. Blood pressure thresholds and neurologic outcomes after endovascular therapy for acute ischemic stroke: an analysis of individual patient data from 3 randomized clinical trials. JAMA Neurol. 2020; 77:622–31.

34. Hong L, Cheng X, Lin L, Bivard A, Ling Y, Butcher K, et al. The blood pressure paradox in acute ischemic stroke. Ann Neurol. 2019; 85:331–9.

35. Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA; IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002; 33:1315–20.

36. Lattanzi S, Silvestrini M, Provinciali L. Elevated blood pressure in the acute phase of stroke and the role of angiotensin receptor blockers. Int J Hypertens. 2013; 2013:941783.

37. Stead LG, Gilmore RM, Vedula KC, Weaver AL, Decker WW, Brown RD Jr. Impact of acute blood pressure variability on ischemic stroke outcome. Neurology. 2006; 66:1878–81.

38. Wahlgren NG, MacMahon DG, De Keyser J, Indredavik B, Ryman T. Intravenous Nimodipine West European Stroke Trial (INWEST) of nimodipine in the treatment of acute ischaemic stroke. Cerebrovasc Dis. 1994; 4:204–10.

39. Horn J, de Haan RJ, Vermeulen M, Limburg M. Very early nimodipine use in stroke (VENUS): a randomized, double-blind, placebo-controlled trial. Stroke. 2001; 32:461–5.

40. Bath PM, Martin RH, Palesch Y, Cotton D, Yusuf S, Sacco R, et al. Effect of telmisartan on functional outcome, recurrence, and blood pressure in patients with acute mild ischemic stroke: a PRoFESS subgroup analysis. Stroke. 2009; 40:3541–6.

41. Sandset EC, Bath PM, Boysen G, Jatuzis D, Kõrv J, Lüders S, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebo-controlled, double-blind trial. Lancet. 2011; 377:741–50.

42. Potter JF, Robinson TG, Ford GA, Mistri A, James M, Chernova J, et al. Controlling hypertension and hypotension immediately post-stroke (CHHIPS): a randomised, placebo-controlled, double-blind pilot trial. Lancet Neurol. 2009; 8:48–56.

43. Robinson TG, Potter JF, Ford GA, Bulpitt CJ, Chernova J, Jagger C, et al. Effects of antihypertensive treatment after acute stroke in the Continue or Stop Post-Stroke Antihypertensives Collaborative Study (COSSACS): a prospective, randomised, open, blinded-endpoint trial. Lancet Neurol. 2010; 9:767–75.

44. ENOS Trial Investigators. Efficacy of nitric oxide, with or without continuing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet. 2015; 385:617–28.

45. Lee M, Ovbiagele B, Hong KS, Wu YL, Lee JE, Rao NM, et al. Effect of blood pressure lowering in early ischemic stroke: meta-analysis. Stroke. 2015; 46:1883–9.

46. Bath PM, Krishnan K. Interventions for deliberately altering blood pressure in acute stroke. Cochrane Database Syst Rev. 2014; 2014:CD000039.

47. Wohlfahrt P, Krajcoviechova A, Jozifova M, Mayer O, Vanek J, Filipovsky J, et al. Low blood pressure during the acute period of ischemic stroke is associated with decreased survival. J Hypertens. 2015; 33:339–45.

48. Vemmos KN, Tsivgoulis G, Spengos K, Zakopoulos N, Synetos A, Manios E, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J Intern Med. 2004; 255:257–65.

49. Stead LG, Gilmore RM, Decker WW, Weaver AL, Brown RD Jr. Initial emergency department blood pressure as predictor of survival after acute ischemic stroke. Neurology. 2005; 65:1179–83.

50. He J, Zhang Y, Xu T, Zhao Q, Wang D, Chen CS, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA. 2014; 311:479–89.

51. PATS Collaborating Group. Post-stroke antihypertensive treatment study: a preliminary result. Chin Med J (Engl). 1995; 108:710–7.

52. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001; 358:1033–41.

53. Yusuf S, Diener HC, Sacco RL, Cotton D, Ounpuu S, Lawton WA, et al. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med. 2008; 359:1225–37.

54. Liu L, Wang Z, Gong L, Zhang Y, Thijs L, Staessen JA, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res. 2009; 32:1032–40.

55. Ovbiagele B, Diener HC, Yusuf S, Martin RH, Cotton D, Vinisko R, et al. Level of systolic blood pressure within the normal range and risk of recurrent stroke. JAMA. 2011; 306:2137–44.

56. Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke. 2004; 35:776–85.

57. Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP, et al. Lower stroke risk with lower blood pressure in hemodynamic cerebral ischemia. Neurology. 2014; 82:1027–32.

58. Rothwell PM, Howard SC, Spence JD; Carotid Endarterectomy Trialists' Collaboration. Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke. 2003; 34:2583–90.

59. Chaturvedi S, Turan TN, Lynn MJ, Kasner SE, Romano J, Cotsonis G, et al. Risk factor status and vascular events in patients with symptomatic intracranial stenosis. Neurology. 2007; 69:2063–8.

60. Park JH, Ovbiagele B, Hong KS, Kwon SU. Association of systolic blood pressure with progression of symptomatic intracranial atherosclerotic stenosis. J Stroke. 2017; 19:304–11.

61. Park JM, Kim BJ, Kwon SU, Hwang YH, Heo SH, Rha JH, et al. Intensive blood pressure control may not be safe in subacute ischemic stroke by intracranial atherosclerosis: a result of randomized trial. J Hypertens. 2018; 36:1936–41.

62. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45:2160–236.