1. For patients with acute ischemic stroke who will receive thrombolytic therapy, antihypertensive treatment is recommended to lower blood pressure to ≤185/110 mmHg. Labetalol or nicardipine can be administered intravenously to achieve this. 2. For patients receiving reperfusion therapy, blood pressure should be maintained at ≤180/105 mmHg during and after treatment. It should be monitored frequently and medications adjusted as needed. 3. For previously untreated patients with a history of ischemic stroke or TIA, initiation of antihypertensive therapy is recommended if blood pressure remains ≥140/90 mmHg after the first few days, with a target of <140/90 mmHg

3. What Is the Appropriate Target Blood Pressure in
Patients With ICH?
 Immediately after an ICH, it is perhaps more appropriate to tailor the target
BP to each patient rather than using a “one size fits all” approach.
 The possibility of increased ICP and a history of chronic untreated
hypertension should be considered while choosing the target.

4. How Fast Should Blood Pressure Be Lowered?
 Results of small studies suggest that rapidly lowering MAP by
approximately 15% does not lower cerebral blood flow, whereas reductions
of 20% can do so.
 Therefore, if BP-lowering is considered, current guidelines suggest
cautious lowering of BP by no more that 20% in the first 24 hours.

6. Should Blood Pressure Be Elevated to Improve Cerebral
Perfusion in Patients With Ischemic Stroke?
 Answer: A few small case series have shown neurological improvement with
induced hypertensive therapy.
 Studies are underway to assess the usefulness of this form of therapy in
patients with a diffusion–perfusion mismatch on MRI.
 In the meantime, it is reasonable to try volume expansion and/or
vasopressors in patients with hypotensive stroke or in patients who have
had a worsening of the neurological deficit in association with a drop in BP.

7. Should Patients on Antihypertensive Agents Have Their
Medications Held or Continued?
 There are no substantial clinical data available to answer this question and a
clinical trial is underway to address this issue (Continue or stop poststroke
antihypertensives study).
 The AHA/ASA guidelines recommend restarting antihypertensives at 24
hours in previously hypertensive neurologically stable patients unless
contraindicated

9. PROGRESS trial
The PROGRESS trial included over 6100 patients (mean age 64 years) with an
ischemic or, less often, hemorrhagic stroke or transient ischemic attack
within the previous five years (median eight months)
The patients were randomly assigned to perindopril or placebo; the diuretic
indapamide was added as necessary in the perindopril group.
The mean baseline blood pressure was 147/86 mmHg; approximately one
half of patients were hypertensive (mean 159/94 mmHg), while remaining
patients had highnormal values (mean 136/79 mmHg).

10.  A reduction in blood pressure of 9/4 mmHg in the perindopril group
compared with placebo decreased the rate of the primary end point of fatal
or nonfatal stroke
 The stroke prevention benefit was related to the degree of blood pressure
reduction, being most prominent (relative risk reduction 43 percent) and
statistically significant in patients treated with combination therapy
(perindopril plus indapamide) who had a 12/5 mmHg mean reduction in
blood pressure compared with placebo
PROGRESS trial

11.  The reduction in recurrent stroke with antihypertensive therapy was seen in
both hypertensive (11.1 versus 16.2 percent, relative risk reduction 32
percent) and nonhypertensive patients (9.1 versus 11.5 percent, relative risk
reduction 21 percent).
 Thus, both the risk of stroke and the absolute benefit from antihypertensive
therapy were greater in the hypertensive patients. Similar findings were
noted when all major vascular events were evaluated.
PROGRESS trial

12. PRoFESS trial
 The PRoFESS trial (Prevention Regimen for Effectively Avoiding Second
Strokes) randomly assigned 20,332 patients with non cardioembolic ischemic
stroke to receive either fixed dose telmisartan (80 mg daily) or placebo.
 All other antihypertensive drugs, except for angiotensin receptor blockers,
were permitted as add on therapy.
 Approximately three quarters of patients had a prior history of hypertension,
and the average blood pressure was 144/84 mmHg in both groups at baseline.

13.  At an average followup of 2.5 years,
 There was no significant difference between the telmisartan and placebo groups in
the primary outcome of recurrent stroke (8.7 versus 9.2 percent, hazard ratio [HR]
0.95, 95% CI 0.861.04),
 or in secondary outcomes including major cardiovascular events (13.5 versus 14.4
percent, HR 0.94, 95% CI 0.871.01).
 Significant benefit compared with placebo would not have been expected since
telmisartan therapy only reduced the blood pressure by an average 3.8/2.0 mmHg
more than placebo.
PRoFESS trial

14. PATS trial
The PATS trial (Poststroke Antihypertensive Treatment Study) randomly assigned 5665
Chinese patients with a history of stroke (mostly ischemic) or TIA to treatment with
indapamide (2.5 mg daily) or placebo .
The average interval from stroke to randomization was 31 months, and the average blood
pressure at randomization was 154/93 mmHg.
At a median followup of two years, active treatment reduced blood pressure by a mean of
6.8/3.3 mmHg.
There were significantly fewer strokes in the active treatment compared with the placebo group
(143 versus 219, hazard ratio [HR] 0.69, 95% CI 0.54–0.89).

15. Meta- analysis
A metaanalysis of eight placebo controlled trials of angiotensin inhibition
included almost 30,000 patients, most of whom came from the PRoFESS trial
.
Antihypertensive therapy (most of the included trials in this metaanalysis
compared angiotensin inhibitors with placebo) resulted in a significant
reduction in major cardiovascular events (13.1 versus 14.7 percent, risk ratio
0.92, 95% CI 0.860.98) and an almost significant reduction in recurrent
stroke (9.0 versus 9.6 percent, risk ratio 0.94, 95% CI 0.871.01).

16. Meta- analysis
 The second metaanalysis was published in 2011 and included 40,300
patients from 16 randomized trials of antihypertensive therapy in patients
with a prior stroke, approximately one half of whom came from PRoFESS .
 Antihypertensive therapy was associated with a significant reduction in
recurrent stroke (relative risk 0.81, 95% CI 0.730.91).

17. A Guideline for Healthcare Professionals From the American Heart
Association/American Stroke Association

18. Introduction
 Treatment of hypertension is possibly the most important intervention for
secondary prevention of ischemic stroke.
 The prevalence among patients with a recent ischemic stroke is ≈70%.
 The risk for a first ischemic stroke is directly related to blood pressure (BP)
starting with an SBP as low as 115 mm Hg.

19. Hypertension Recommendations
1. Initiation of BP therapy is indicated for previously untreated patients with ischemic
stroke or TIA who, after the first several days, have an established BP ≥140 mm Hg
systolic or ≥90 mm Hg diastolic (Class I; Level of Evidence B). Initiation of therapy for
patients with BP <140 mm Hg systolic and <90 mm Hg diastolic is of uncertain benefit
(Class IIb; Level of Evidence C). (Revised recommendation)
2. Resumption of BP therapy is indicated for previously treated patients with known
hypertension for both prevention of recurrent stroke and prevention of other vascular
events in those who have had an ischemic stroke or TIA and are beyond the first
several days (Class I; Level of Evidence A). (Revised recommendation)

20. 3. Goals for target BP level or reduction from pretreatment baseline are
uncertain and should be individualized, but it is reasonable to achieve
a systolic pressure <140 mm Hg and a diastolic pressure <90 mm Hg
(Class IIa; Level of Evidence B).
For patients with a recent lacunar stroke, it might be reasonable to
target an SBP of <130 mm Hg (Class IIb; Level of Evidence B). (Revised
recommendation)
Hypertension Recommendations

21.  4. Several lifestyle modifications have been associated with BP reductions and are a
reasonable part of a comprehensive antihypertensive therapy (Class IIa; Level of
Evidence C).
 These modifications include
 Salt restriction;
 Weight loss;
 The consumption of a dietrich in fruits, vegetables, and low-fat dairy products;
 Regular aerobic physical activity; and
 Limited alcohol consumption.
Hypertension Recommendations

22.  5. The optimal drug regimen to achieve the recommended level of
reductions is uncertain because direct comparisons between
regimens are limited.
 The available data indicate that diuretics or the combination of
diuretics and an angiotensin-converting enzyme inhibitor is useful
(Class I; Level of Evidence A).
Hypertension Recommendations

23.  6. The choice of specific drugs and targets should be individualized on
the basis of pharmacological properties, mechanism of action, and
consideration of specific patient characteristics for which specific
agents are probably indicated (eg, extracranial cerebrovascular occlusive
disease, renal impairment, cardiac disease, and DM) (Class IIa; Level of
Evidence B).
Hypertension Recommendations

24.  The management of blood pressure in acute stroke depends on the type of
stroke.
 For patients with acute ischemic stroke who will receive thrombolytic
therapy, antihypertensive treatment is recommended so that systolic blood
pressure is ≤185 mmHg and diastolic blood pressure is ≤110 mmHg

25. Potential approaches to arterial hypertension in patients with acute
ischemic stroke who are candidates for acute reperfusion therapy
Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mmHg
Labetalol 10 to 20 mg intravenously over 1 to 2 minutes, may repeat one time; or
Nicardipine 5 mg/hour intravenously, titrate up by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; when desired
blood pressure reached, adjust to maintain proper blood pressure limits; or
Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
If blood pressure is not maintained at or below 185/110 mmHg, do not administer rtPA
Management to maintain blood pressure at or below 180/105 mmHg during and after acute reperfusion therapy
Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and
then every hour for 16 hours
If systolic blood pressure is >180 to 230 mmHg or diastolic is >105 to 120 mmHg:
Labetalol 10 mg intravenously followed by continuous infusion 2 to 8 mg/min; or
Nicardipine 5 mg/hour intravenously, titrate up to desired effect by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour
If blood pressure is not controlled or diastolic blood pressure >140 mmHg, consider intravenous sodium nitroprusside

26. Disorders of Glucose Metabolism and DM
Recommendations
 1. After a TIA or ischemic stroke, all patients should probably be screened
for DM with testing of fasting plasma glucose, HbA1c, or an oral glucose
tolerance test.
 Choice of test and timing should be guided by clinical judgment and
recognition that acute illness may temporarily perturb measures of plasma
glucose.
 In general, HbA1c may be more accurate than other screening tests in the
immediate postevent period (Class IIa; Level of Evidence C). (New
 recommendation)

27.  2. Use of existing guidelines from the ADA forglycemic control and
cardiovascular risk factor management is recommended for patients
with an ischemic stroke or TIA who also have DM or pre-DM (Class I;
Level of Evidence B).

29. Introduction
Stroke ranks as
the fourth-
leading cause
of death in the
United States.
Globally, over
the past 4
decades, stroke
incidence rates
have fallen by
42% in high-
income
countries and
increased by
>100% in low-
and middle-
income
countries.
Stroke
incidence
rates in low-
and middle-
income
countries now
exceed those
in high-
income
countries

31. Definition of Classes and Levels of Evidence Used
in AHA/ASA Recommendations

32. Assessing the Risk of First Stroke: Recommendations
The use of a risk assessment tool such as the AHA/ ACC CV Risk
Calculator (http://my.americanheart. org/cv risk calculator ) is
reasonable because these tools can help identify individuals who
could benefit from therapeutic interventions and who may not be
treated on the basis of any single risk factor.
These calculators are useful to alert clinicians and patients of
possible risk, but basing treatment decisions on the results needs to
be considered in the context of the overall risk profile of the patient
(Class IIa; Level of Evidence B).

33. Physical Inactivity: Recommendations
1. Physical activity
is recommended
because it is
associated with a
reduction in the
risk of stroke
(Class I; Level of
Evidence B).
2. Healthy adults
should perform at
least moderate- to
vigorous-intensity
aerobic physical
activity at least 40
min/d 3 to 4 d/wk
(Class I; Level of
Evidence B).

34. Dyslipidemia: Recommendations
1. In addition to therapeutic lifestyle changes, treatment with an HMG
coenzyme-A reductase inhibitor (statin) medication is recommended for the
primary prevention of ischemic stroke in patients estimated to have a high 10-
year risk for cardiovascular events as recommended in the 2013 “ACC/AHA
Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Risk in Adults”(Class I; Level of Evidence A).
2. Niacin may be considered for patients with low HDL cholesterol or elevated
Lp(a), but its efficacy in preventing ischemic stroke in patients with these
conditions is not established. Caution should be used with niacin because it
increases the risk of myopathy (Class IIb; Level of Evidence B).

35. Dyslipidemia: Recommendations
3. Fibric acid derivatives may be considered for patients with
hypertriglyceridemia, but their efficacy in preventing ischemic
stroke is not established (Class IIb; Level of Evidence C).
4. Treatment with nonstatin lipid-lowering therapies such as fibric
acid derivatives, bile acid sequestrants, niacin, and ezetimibe may
be considered in patients who cannot tolerate statins, but their
efficacy in preventing stroke is not established (Class IIb; Level of
Evidence C).

36. Diet and Nutrition: Recommendations
1. Reduced intake of sodium and increased intake of potassium as indicated in the US
Dietary Guidelines for Americans are recommended to lower BP (Class I; Level of Evidence
A).
2. A DASH-style diet, which emphasizes fruits, vegetables, and low-fat dairy products and
reduced saturated fat, is recommended to lower BP1 (Class I; Level of Evidence A).
3. A diet that is rich in fruits and vegetables and thereby high in potassium is beneficial and
may lower the risk of stroke (Class I; Level of Evidence B).
4. A Mediterranean diet supplemented with nuts may be considered in lowering the risk of
stroke (Class IIa; Level of Evidence B).

37. Hypertension: Recommendations
1. Regular BP screening
and appropriate
treatment of patients
with hypertension,
including lifestyle
modification and
pharmacological therapy,
are recommended (Class
I; Level of Evidence A).
2. Annual screening
for high BP and
health-promoting
lifestyle
modification are
recommended for
patients with
prehypertension
(SBP of 120 to 139 mm
Hg or DBP of 80 to 89
mm Hg) (Class I;
Level of Evidence A).
3. Patients who have
hypertension should
be treated with
antihypertensive
drugs to a target BP
of <140/90 mm Hg
(Class I; Level of
Evidence A).

38. Hypertension: Recommendations
4. Successful reduction of BP is more important in reducing stroke risk
than the choice of a specific agent, and treatment should be
individualized on the basis of other patient characteristics and
medication tolerance (Class I; Level of Evidence A).
5. Self-measured BP monitoring is recommended to improve BP
control. (Class I; Level of Evidence A).

39. Obesity and Body Fat Distribution:
Recommendations
1. Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2)
individuals, weight reduction is recommended for lowering BP (Class
I; Level of Evidence A).
2. Among overweight (BMI=25 to 29 kg/m2) and obese (BMI >30 kg/m2)
individuals, weight reduction is recommended for reducing the risk of
stroke (Class I; Level of Evidence B).

40. Diabetes: Recommendations
1. Control of BP in accordance with an AHA/ACC/ CDC Advisory to a
target of <140/90 mm Hg is recommended in patients with type 1 or
type 2 diabetes mellitus (Class I; Level of Evidence A).
2. Treatment of adults with diabetes mellitus with a statin, especially
those with additional risk factors, is recommended to lower the risk of
first stroke (Class I; Level of Evidence A).

41. Diabetes: Recommendations
 3. The usefulness of aspirin for primary stroke prevention for patients with
diabetes mellitus but low 10-year risk of CVD is unclear (Class IIb; Level of
Evidence B).
 4. Adding a fibrate to a statin in people with diabetes mellitus is not useful
for decreasing stroke risk (Class III; Level of Evidence B).