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under way. 4. General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke (Class I, Level of Evidence B). This recommendation has not changed from previous statements. 5. The management of arterial hypertension remains controversial. Data to guide recommendations for treatment are inconclusive or conflicting. Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke. Until more definitive data are available, it is generally agreed that a cautious approach to the treatment of arterial hypertension should be recommended (Class I, Level of Evidence C). Patients who have other medical indications for aggressive treatment of blood pressure should be treated. This recommendation has not changed from previous statements. 6. Patients who have elevated blood pressure and are otherwise eligible for treatment of rtPA may have their blood pressure lowered so that their systolic blood pressure is ≤185 mm Hg and their diastolic blood pressure is ≤110 mm Hg (Class I, Level of Evidence B) before lytic therapy is started. This recommendation has not changed from previous statements. If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before treating with rtPA and maintained below 180/105 mm Hg for at least the first 24 hours after intravenous rtPA treatment. Because the maximum interval from stroke onset until treatment with rtPA is short, many patients with sustained hypertension above recommended levels cannot be treated with intravenous rtPA. 7. Until other data become available, consensus exists that the previously described blood pressure recommendations should be followed in patients undergoing other acute interventions to recanalize occluded vessels, including intra-arterial thrombolysis (Class I, Level of Evidence C). This recommendation has been added since the previous guideline. 8. It is generally agreed that patients with markedly elevated blood pressure may have their blood pressure lowered. A reasonable goal would be to lower blood pressure by ≈15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mm Hg or the diastolic blood pressure is >120 mm Hg (Class I, Level of Evidence C). This recommendation has changed from previous statements in that a potential goal for lowering blood pressure is now included. Research testing the effects of early treatment of arterial hypertension on outcomes after stroke is under way. The panel looks forward to any data that will clarify this management decision. 9. It is generally agreed that the cause of arterial hypotension in the setting of acute stroke should be sought. Hypovolemia should be corrected with normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected (Class I, Level of Evidence C). This recommendation was not included in previous statements. The utility of volume expansion and the use of medications to increase blood pressure to treat ischemic stroke are discussed elsewhere in the present guideline. 10. It is generally agreed that hypoglycemia should be treated in patients with acute ischemic stroke (Class I, Level of Evidence C). The goal is to achieve normoglycemia. Marked elevation of blood glucose levels should be avoided. This recommendation was included in previous statements. Class II Recommendations 1.No data are
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