Management of Stroke with Hypertension

1. Stroke with Hypertension
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital

2. Introduction
 Stroke has a global incidence of 15 million people per year, is the
third leading cause of death and is the most common cause of
disability in the western world.
 High-blood pressure (BP) is the leading modifiable risk factor for
both ischaemic and haemorrhagic stroke affecting 1 billion people
worldwide.
 In acute stroke, 75% of patients have high BP and 50% of those
have a prior history of hypertension.
 Although BP spontaneously falls in two-thirds of patients in the
first week following stroke, one-third remain hypertensive and
have an increased risk of a poor outcome.
Appleton JP, Sprigg N, Bath PM. Blood pressure management in acute stroke. Stroke and Vascular Neuro
2016;1:e000020. doi:10.1136/svn-2016-000020
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3. HYPERTENSIVE INTRACEREBRAL
HEMORRHAGE
 Patho-physiologically, long-standing poorly controlled HTN leads
to formation of microaneurysms of perforating arteries (Charcot-
Bouchard aneurysms)
 These small penetrating arteries can leak or rupture leading to
hemorrhagic strokes
 The most common locations for hypertensive hemorrhages
include the basal ganglia (particularly the putamen), thalamus,
pons, and cerebellum
(DiMuzio, Radiopedia, 2017)
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5. In the long term, HTN causes atherosclerosis
(hardening of the arteries), which can cause
blockage of the small blood vessels in the brain
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6. Acute Stroke Management
1. Hypotension and hypovolemia should be avoided to facilitate
systemic perfusion
2. Before intravenous fibrinolytic therapy is administered, BP should
be <185/110 mm Hg and <180/105 mm Hg in the first 24 hours after
such treatment
3. If mechanical thrombectomy is planned and intravenous
thrombolytic therapy has not been given, BP should be ≤185/110 mm
Hg before the procedure and ≤180/105 mm Hg in the first 24 hours
after the procedure
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
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7. 4. In patients who undergo successful reperfusion with mechanical
thrombectomy, it may be reasonable to maintain BP <180/105 mm Hg
5. Early treatment of hypertension may be indicated in the presence of
certain comorbid conditions (eg, heart failure, aortic dissection, acute
myocardial infarction
6. The usefulness of BP augmentation in acute ischemic stroke remains
uncertain
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
Acute Stroke Management…
NYN/DMA/BPL

8. 7. For patients who are not treated with intravenous fibrinolytic
therapy or mechanical thrombectomy:
– If BP is ≥220/120 mm Hg and there are no comorbid conditions
requiring acute BP-lowering treatment, it is reasonable to initially
lower BP by 15% although the benefit of lowering or reinstituting BP
therapy in the first 48 to 72 hours is uncertain and
– Lowering BP when it is <220/120 mm Hg in the first 48 to 72 hours
seems to be a safe strategy but does not lower mortality or improve
functional outcome
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
Acute Stroke Management…
NYN/DMA/BPL

9.  Finally, it is reasonable to restart BP-lowering
medication in patients who have a BP >140/90
mm Hg once the patient is neurologically stable.
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
Acute Stroke Management…
NYN/DMA/BPL

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12. Recurrent Stroke Prevention
1. For those with SBP ≥140 mm Hg or DBP ≥90 mm Hg, BP-
lowering therapy is reasonable, and a target for BP lowering of
<140/90 mm Hg is reasonable and
2. For those with small vessel (ie, lacunar) cerebral ischemia, a
SBP-lowering target of <130 mm Hg is reasonable
3. For those with a stroke or TIA, a BP-lowering goal of <130/80
mm Hg may be reasonable
(Hypertension. 2020;76:1688-1695.
DOI:
10.1161/HYPERTENSIONAHA.120.1465
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13. BP-lowering therapy
1. Restart BP-lowering medications within several days after the
index stroke or TIA to reduce the risk of subsequent major
vascular events
2. Any of a number of medication classes may be used to lower
BP; however, a thiazide diuretic, ACE inhibitor, or angiotensin
receptor blocker or a combination of the first 2 medication
choices may be administered
3. Individualize the choice of BP-lowering medication based on
patient comorbidities and
4. The usefulness of BP-lowering in people with stroke or TIA
and SBP <140 mm Hg or DBP <90 mm Hg is not well established
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
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14. First Stroke Prevention
1. Regular screening of BP and treatment of elevated BP by
lifestyle and pharmacological measures
2. Lower BP to a target of <130/80 mm Hg
3. Based on patient comorbidities choose appropriate BP
lowering medications, however, successful lowering of BP is
emphasized over specific classes of BP-lowering medications
save for those with specific comorbidities requiring a specific
BP-lowering medication class and
4. Self-measurement of BP is recommended
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
NYN/DMA/BPL

15. Intracerebral Hemorrhage
1. When SBP is between 150 and 220 mm Hg, acute BP lowering
may be effective in relation to improvement of functional
outcome and is safe and
2. When SBP is >220 mm Hg, it may be reasonable to lower BP
by administration of a continuous intravenous infusion
medication with initiation of frequent BP monitoring
Aim for a target SBP of 140 to 160 mm Hg early after the
onset of ICH.
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
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16. Antihypertensive Drug
 Angiotensin receptor blockers
 ACE inhibitors
 Diuretics,
 Calcium channel blockers,
 β-blockers
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
NYN/DMA/BPL

17.  Most adults with hypertension, especially Black
patients and those with a high starting level of BP,
should be treated with ≥2 antihypertensive drugs, in
combination with lifestyle modification, to control
their BP.
 Drugs with complementary mechanisms of action,
such as a diuretic and renin-angiotensin system
blockers, are preferred for combinations and should
be administered as a single-pill combination when
possible.
(Hypertension. 2020;76:1688-1695. DOI:
10.1161/HYPERTENSIONAHA.120.14653.)
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18. European Cardiology Review 2019;14(2):111–5. DOI:
https://doi.org/10.15420/ecr.2019.11.1
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19. In summary
 BP lowering is a reasonable overall strategy as at the very
least it will reduce risk of stroke and other cardiovascular
diseases.
 There is no definitive evidence that one class of
antihypertensive drugs is superior to another for
achievement of cognitive maintenance. It is reasonable to
consider the SPRINT BP lowering therapeutic regimen and BP
lowering target (<120 mm Hg systolic).
 It is reasonable to control BP in middle-aged and young
elderly to lower risk of cognitive impairment and dementia.
P.B. Gorelick et al. International Journal of Cardiology Hypertension 3 (2019) 100021
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20.  In those with stroke, lowering of blood pressure may
reduce the risk of post-stroke dementia.
 In those at risk for vascular cognitive impairment (e.g.,
multiple cardiovascular risks), lowering of BP may reduce
the risk of cognitive impairment.
 For persons 80 years of age and older, the usefulness of BP
lowering for prevention of dementia in not established. In
fact, there is concern that with BP lowering in for
example certain older patients, there may be an increase
of small subcortical infarcts based on brain blood pressure
gradients
P.B. Gorelick et al. International Journal of Cardiology Hypertension 3 (2019) 100021
In summary……
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21. Thank You
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