How Blood Pressure Is Managed After an Ischemic Stroke

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High blood pressure, also called hypertension, is a widely recognized risk factor for stroke. So it may surprise some people to see that, after someone has had a stroke, doctors may stop blood pressure medications and allow the pressure to seemingly soar. Why is that?

Nurse taking man's blood pressure at clinic

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Permissive Hypertension

Ischemic stroke is caused by a blockage in a blood vessel. Blood needs to be able to flow through to deliver oxygen and also remove toxic by-products from the brain. When this cannot occur due to blockage, as many as 1.9 million cells of brain tissue can die each minute.

Part of the primary treatment goal for ischemic stroke is to encourage blood to flow through a tighter space. This can be achieved in a few ways. In some cases, blood may be able to flow through an alternative blood vessel to reach the brain. In other cases, a blocked vessel may reopen partially, allowing some blood to flow through.

One strategy for encouraging blood flow is to increase blood pressure to push the blood through those narrower blood vessels. For patients taking blood pressure medication, this can mean stopping that medication and allowing the blood pressure to rise.

The strategy of "permissive hypertension" involves stopping blood pressure medications for a set period of time after a stroke—usually no more than 24 to 48 hours—in order to widen blood vessels and improve blood flow in the brain.

During this time, the systolic blood pressure may rise as high as 220 mmHg (or 185 mmHg if the clot-busting drug tissue plasminogen activator is used). Once the blockage has been addressed, your doctor will work to determine how best to manage your blood pressure level until it's back to normal. Factors that influence how your blood pressure should be managed include how severe the stroke was, whether or not you received a clot-buster drug, and your overall state of health.

Guidelines jointly published by the American Heart Association and American Stroke Association on the early treatment of ischemic stroke note that there is no one ideal blood pressure reading for patients experiencing ischemic stroke. The guidelines do recommend carefully lowering blood pressure in patients with elevated levels who are otherwise eligible for treatment with clot-busting medication (IV alteplase) as this may help improve overall outcomes.

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