12
Treatment
Î Patients who have elevated BP and are otherwise eligible for
treatment with IV rtPA should have their BP carefully lowered
(Table 7) so that their systolic BP is <185 mm Hg and their diastolic
BP is <110 mm Hg before fibrinolytic therapy is initiated (I-B).
• Until other data become available, consensus exists that the previously described
BP recommendations should be followed in patients undergoing other acute
interventions to recanalize occluded vessels, including intra-arterial fibrinolysis
(I-C).
Î Restarting antihypertensive medications is reasonable after the first
24 hours for patients who have preexisting hypertension and are
neurologically stable unless a specific contraindication to restarting
treatment is known (IIa-B).
Note: Evidence from one clinical trial indicates that initiation of antihypertensive
therapy within 24 hours of stroke is relatively safe.
Î In patients with markedly elevated BP who do not receive fibrinolysis,
a reasonable goal is to lower BP by 15% during the first 24 hours after
onset of stroke (I-C).
Note: The level of BP that would mandate such treatment is not known, but
consensus exists that medications should be withheld unless the systolic BP is
>220 mm Hg or the diastolic BP is >120 mm Hg.
• No data are available to guide selection of medications for the lowering of BP in
the setting of acute ischemic stroke. The antihypertensive medications and doses
included in Table 7 are reasonable choices based on general consensus (IIa-C).
Î Until more definitive data are available, the benefit of treating arterial
hypertension in the setting of acute ischemic stroke is not well
established (IIb-C).
Note: Patients who have malignant hypertension or other medical indications for
aggressive treatment of BP should be treated accordingly.
The management of arterial hypertension in patients not undergoing reperfusion
strategies remains challenging. Data to guide recommendations for treatment are
inconclusive or conflicting.
Î Many patients have spontaneous declines in BP during the first
24 hours after onset of stroke.
Î Correct hypovolemia with IV normal saline, and correct cardiac
arrhythmias that might be reducing cardiac output (I-C).
Î Treat hypoglycemia (blood glucose <60 mg/dL) in patients with acute
ischemic stroke (I-C).
Note: The goal is to achieve normoglycemia.
• Evidence indicates that persistent in-hospital hyperglycemia during the first
24 hours after stroke is associated with worse outcomes than normoglycemia,
and thus it is reasonable to treat hyperglycemia to achieve blood glucose levels
in a range of 140-180 mg/dL and to monitor closely to prevent hypoglycemia in
patients with acute ischemic stroke (IIa-C).
