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data are available.. Approach to Arterial Hypertension in Acute Ischemic Stroke When treatment is indicated, lowering the blood pressure should be done cautiously. Some strokes may be secondary to hemodynamic factors, and a declining blood pressure may lead to neurological worsening. A reasonable goal would be to lower blood pressure by 15% to 25% within the first day.263 Because no data support the administration of any specific antihypertensive agent in the setting of acute ischemic stroke, the treating physician should select medications for lowering blood pressure on a case-by-case basis. The recommendations in are based on consensus and reflect the goal of rapidly reducing blood pressure, but, at the same time, the potential for a rapid reversal if the drop in blood pressure leads to neurological worsening. The selection of an agent may be influenced by other medical conditions; for example, the presence of asthma would contraindicate the administration of a β-blocker. Because of a prolonged effect and the potential for a precipitous decline in blood pressure associated with the sublingual administration of nifedipine, this agent with this route of administration is not recommended.264 Among patients who are candidates for treatment with intravenous rtPA, attention to management of blood pressure is critical before, during, and after the administration of the medication.263 Excessively high blood pressure is associated with an increased risk of symptomatic hemorrhagic transformation.66,262,265,266 Failure to meet the blood pressure parameters of previous guidelines may be one of the explanations for an increased risk of hemorrhagic complications after administration of rtPA.267–269 Presumably, similar risks of bleeding will be associated with elevations of blood pressure among patients receiving other acute pharmacological or mechanical interventions to improve the perfusion to the brain. The suggestion to withhold such therapies among patients with markedly elevated blood pressure is based on potential safety risks. Conversely, excessively high blood pressures could be lowered successfully with medications to permit treatment with intravenous rtPA. Arterial hypertension is a recognized risk factor for stroke and recurrent stroke. Many patients were taking medications before their stroke or are found to have sustained hypertension after their stroke. These patients will need long-term antihypertensive treatment; the primary question is the timing of the institution of such therapy. Limited data are available to guide these decisions. On the basis of the trial of candesartan, it appears that medications can be administered with a reasonable degree of safety when started ≈1 day after stroke.258 The timing of the reinstitution of treatment and the selection of medications will depend on the patient’s neurological status, the underlying stroke mechanism, the patient’s ability to swallow medications, and the presence of concomitant diseases. Presumably, most patients with mild to moderate strokes who are not at high risk for increased intracranial pressure may have their prestroke antihypertensive medications restarted 24 hours after their vascular event. The panel strongly endorses clinical research that will provide information about the safety and efficacy of restarting antihypertensive therapy among patients with stroke. E. Arterial Hypotension Persistent arterial hypotension is rare among patients with acute ischemic stroke, but it is associated with an increased likelihood of an unfavorable outcome.270 Castillo et al240 noted that the rates of neurological worsening, poor neurological outcomes, or death increased when the baseline systolic blood pressure was <100 mm Hg or the diastolic blood pressure was <70 mm Hg. The cause of
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