European Stroke Organisation guidelines
BP lowering in acute stroke:
Acute Ischaemic Stroke:
SBP <220mmHg
Don't intervene with BP meds. Check for pain, full bladder etc. Treat other symptoms of stroke (eg, headache, agitation, nausea, vomiting). Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia
SBP >220mm Hg
Safe and reasonable to intervene but no evidence of improvement in patient outcomes. Options include:
- Labetalol 10 to 20 mg IV for 1 to 2 min. May repeat or double every 10 min (max dose 300 mg), or give initial labetalol dose then start labetalol drip at 2 to 8 mg/min
- OR
- Nicardipine 5 mg/h IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to max of 15 mg/h. Aim for a 10% to 15% reduction in BP
- If DBP remains >140 mmHg, consider Nitroprusside 0.5 µg/kg per minute IV infusion as initial dose with continuous BP monitoring. Aim for a 10% to 15% reduction in blood pressure
Acute Haemorrhagic Stroke:
Continued uncertainty, with no hard evidence of any improvement in patient outcome.
There is some minor evidence of improved surrogate endpoints of uncertain clinical significance (haematoma growth) and an expert consensus recommendation to lower BP in acute bleeds that, to my mind, seems as yet mostly divorced from hard evidence. Medication options as above.
Links>
- European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage May 2021 (https://doi.org/10.1177/23969873211012133)
- NICE 2007 [Alteplase in Stroke] . Local copies full guideline (pdf), quick reference (pdf)
- [Cochrane review] of thrombolysis in acute ischaemic stroke
- Stroke Alteplase calculator
- CUH Stroke pathway
- MUH Stroke pathway
- TIA
- Stroke Fibrinolysis/Thrombolysis