European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage.

Thorsten Steiner,Else Charlotte Sandset,Craig S Anderson,Avtar Lal,Lisa S Manning,Philip M Bath,Hanne Christensen,Urs Fischer,Georgios Tsivgoulis,Simona Sacco,Dariusz Gąsecki

doi:10.1177/23969873211012133

Abstract

The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke.The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups.There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.

Highlights

Elevated blood pressure levels are common in patients with acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH), but the pathophysiology of the hypertensive response is poorly understood.[1]
Current European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines do not recommend blood pressure lowering in the pre-hospital setting[24] and the American Heart Association (AHA)/American Stroke Association (ASA) have no specific recommendations for blood pressure management for patients with suspected stroke in this setting.[25]
In hospitalised patients with acute ischaemic stroke and blood pressure < 220/110 mm Hg not treated with intravenous thrombolysis or mechanical thrombectomy, we suggest against the routine use of blood pressure lowering agents at least in first 24 hours following symptom onset, unless this is necessary for a specific comorbid condition

Summary

Introduction

Elevated blood pressure levels (systolic blood pressure !140 mm Hg and/or diastolic blood pressure !90 mm Hg) are common in patients with acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH), but the pathophysiology of the hypertensive response is poorly understood.[1]. As randomised-controlled clinical trials (RCTs) of this topic are limited and challenging, clinical decisions are often made on the basis of observational studies that are prone to bias, confounding and random error.[2,3,4,5] Theoretical concepts and pathophysiological arguments are used to defend arguments for and against alteration of blood pressure in the setting of acute stroke; to reduce the risk of stroke recurrence, cerebral oedema, reperfusion haemorrhage for AIS patients after reperfusion therapies, and reduce haematoma expansion and cerebral oedema in ICH; to avoid impairment of cerebral perfusion to viable ischaemic tissue in the presence of altered autoregulation.[6,7] Whilst most attention has been focused on the avoidance of hypertension, drug-induced hypertension has been proposed as a potential therapeutic strategy to increase cerebral perfusion in some AIS patients.[8].

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