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Guidelines for BP Management in Acute Stroke

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Eligible for IV thrombolytic therapy (with the exception of elevated BP)

  • Pretreatment
    • Systolic greater than 185 OR diastolic greater than 110
      • Labetalol 10 - 20 mg IV over 1 - 2 min
      • nitropaste 1 - 2 in
      • if still elevated,
        • May repeat or double labetalol every 10 min to maximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 2 - 8 mg/min
        • Nicardipine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15 mg/h
        • if blood pressure is not controlled by labetolol or nicardipine, consider sodium nitroprusside or rule out other cause of acute hypertension such as hypertensive urgency
  • During/after treatment
    1. Monitor blood pressure
      • Check blood pressure every 15 min for 2 h, then every 30 min for 6 h, and finally every hour for 16 h
    2. Diastolic greater than 140
      • Sodium nitroprusside 0.5 mcg/kg/min IV infusion as initial dose and titrate to desired blood pressure
    3. Systolic greater than 230 OR diastolic 121 – 140.
      • Option 1
        • Labetalol 10 mg IV for 1 - 2 min
        • May repeat or double labetalol every 10 min to maximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 2 - 8 mg/min
      • Option 2
        • Nicardipine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15 mg/h; if blood pressure is not controlled by labetolol or nicardipine, consider sodium nitroprusside.
    4. Systolic 180 - 230 OR diastolic 105 - 120
      • Labetalol 10 mg IV for 1 - 2 min
      • May repeat or double labetalol every 10 - 20 min to maximum dose of 300 mg or give initial labetalol dose, then start labetalol drip at 2 - 8 mg/min

Not eligible for thrombolytic therapy (for reasons other than just elevated BP )

  • Systolic less than or = 220 OR diastolic less than or = 120
    • Observe unless other end-organ involvement (eg, aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive encephalopathy)
    • Treat other symptoms of stroke (eg, headache, pain, agitation, nausea, vomiting)
    • Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia
  • Systolic greater than 220 OR diastolic 121 - 140. 2 options:
    • Option 1
      • Labetalol 10 - 20 mg IV for 1 - 2 min
      • May repeat or double every 10 min (max dose 300 mg)
      • Systolic greater than 220 OR diastolic 121 - 140
    • Option 2
      • 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% - 15% reduction in blood pressure
  • Diastolic greater than 140
    • Nitroprusside 0.5 mcg/kg/min IV infusion as initial dose with continuous blood pressure monitoring
    • Aim for a 10% - 15% reduction in blood pressure

Authoring Information

Reviewed/Approved by: Schwamm, Lee, M.D. on behalf of ASQT

Last updated: 12/23/2009

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This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.