Blood Pressure Management in the First 24 Hours After Acute Ischemic Stroke

Blood Pressure Management in the First 24 Hours After Acute Ischemic Stroke

Source:
Medscape Medical News; ACC/AHA (2019 Stroke Guideline); ESO (European Stroke Organisation, 2021); ESC (ESC-aligned via ESO); ESH (2023 Hypertension Guideline); ISH (2020 Global Hypertension Guideline)

Key points:
• Do not aggressively lower BP in the first 24 hours after ischemic stroke.
• Permissive hypertension is recommended to maintain cerebral perfusion.

Blood pressure thresholds:
• No thrombolysis planned:
• Treat BP only if ≥220/120 mm Hg.
• If treated, lower BP gradually (≈15% max in first 24 h).
• IV thrombolysis (alteplase/tenecteplase):
• BP must be <185/110 mm Hg before treatment.
• Maintain <180/105 mm Hg for 24 h after thrombolysis.
• Mechanical thrombectomy:
• Similar targets: <185/110 pre-procedure, then <180/105.
• Restart chronic antihypertensives after neurologic stability (usually ≥24 h).
• Treat hypotension, hypoxia, fever, and hyperglycemia promptly.

Bottom line:

In the first 24 hours post-stroke, protect brain perfusion first.
Treat BP only when very high or when reperfusion therapy requires it, and always gradually.
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AHA/ACC 2025 Hypertension Guideline
https://professional.heart.org/en/guidelines-statements/2025-ahaaccaanpaapaabcaccpacpmagsamaaspcnmapcnasgim-guideline-for-thecir0000000000001356
AHA/ASA 2019 Stroke Guideline (BP management)
• Full guideline (2019) on early management of ischemic stroke:
https://www.ahajournals.org/doi/10.1161/STR.0000000000000211

ESO Guideline — BP management in acute stroke (2021)
https://eso-stroke.org/guidelines/

ISH 2020
https://ish-world.com/ish-guidelines/

ESH 2023:
https://www.eshonline.org/esh-guidelines/