Management of High Blood Pressure in Acute Ischaemic Stroke

Abstract

Increased blood pressure (BP) is a common problem in acute ischaemic stroke (AIS). The acute hypertensive response in stroke is of prognostic relevance. The pathophysiology of high BP in stroke is complex and poorly understood. The available evidence is insufficient to guide therapeutic decisions and does not show that lowering BP reduces mortality or disability in patients with subacute ischaemic stroke. There are some hints of the possible efficacy of very early BP lowering (within 6 h after stroke onset). Nevertheless, the management of BP immediately after stroke onset is largely empiric. It is reasonable to withhold BP-lowering drugs until patients are medically and neurologically stable. Immediately restarting pre-stroke BP-lowering drugs may increase disability. The timing of the BP intervention might be crucial. However, more research is needed to identify patients most likely to benefit from lowering BP in acute stroke, as well as the time window in which the response to treatment is likely to be favourable. Subtyping of stroke according to the underlying cause, advanced neuroimaging tools visualizing tissue at risk of infarction and complete cerebral infarctions, as well as a detailed individual history of the patient’s comorbidities, including identification of signs and symptoms of hypertensive target organ damage, might all help to stratify BP policy in AIS in the future trials that are required.