HTN in Acute Ischemic Stroke - Management

Emergency Administration of Anti-HTN agents should be withheld unless the diastolic BP is >120 mm Hg or unless the systolic BP is >220 mm Hg.

Patient is eligible for IV rtPA or other acute reperfusion intervention. BP should be <185/110 mm Hg. If not give:

• • Labetalol 10 - 20 mg IV x 1 - 2 min, may repeat x 1.

  • OR

  • Nitropaste 1 - 2 inches

  • OR

  • Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5 - 15 min intervals, maximum dose 15 mg/h; when desired BP attained, reduce to 3 mg/h

If BP does not decline and remains >185/110 mm Hg, do not adminster rtPA

BP control: Keep BP 160/90 (MAP: 110) or decrease by 15%. Check Pt. clinically.

CPP >60 - 80

Do not use:

• Sodium nitroprusside

• NTG

• Hydralazine

• Enalaprilat

Ideal drug to use: ▼ BP, ▼ ICP, ▲ CPP = sodium thiopental.

Nicardipine is better than labetalol

Management of BP during and after treatment with rtPA or other acute reperfusion intervention

• • Monitor BP q15 min during treatment and then q15 min x 2 hrs after treatment, then q30 min x 6 hrs, and then q1hr x 16 hrs

  • SBP 180 - 230 mm Hg or DBP 105 - 120 mm Hg

    • Labetalol 10 mg IV x 1 - 2 min, may repeat q10 - 20 min, max dose of 300 mg.

      • OR

    • Labetalol 10 mg IV followed by an infusion at 2 - 8 mg/min

  • SBP >230 mm Hg or DPB 121 - 140 mm Hg

    • Labetalol 10 mg IV x 1 - 2 min, may repeat q10 - 20 min, max dose of 300 mg

      • OR

    • Labetalol 10 mg IV followed by an infusion at 2 - 8 mg/min

      • OR

    • Nicardipine infusion, 5 mg/h, titrate up to desired effect by increasing 2.5 mg/h q5 min to maximum strength of 15 mg/h

  • If BP not controlled, consider sodium nitroprusside.

After IV tPA, BP should be maintained <180/105 for 24 hours