7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Official reprint from UpToDate www.uptodate.com 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved. Antihypertensive therapy for secondary stroke prevention : Raymond R Townsend, MD, Natalia S Rost, MD, MPH, Adam de Havenon, MD, MS : George L Bakris, MD, Scott E Kasner, MD : John P Forman, MD, MSc, John F Dashe, MD, PhD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jun 2023. This topic last updated: Nov 03, 2022. INTRODUCTION Hypertension is a major risk factor for stroke and transient ischemic attack (TIA) [1]. The risk can be reduced by persistent correction of the hypertension [2]. (See "Overview of primary prevention of cardiovascular disease", section on 'Hypertension control'.) In addition, among patients who have had a stroke or TIA, antihypertensive therapy can reduce the rate of recurrence. (See 'Management after the acute phase of stroke' below.) This topic will review the management of blood pressure for prevention of a recurrent stroke, including the timing of initiation (or reinstatement) of antihypertensive therapy following stroke or TIA, the choice of antihypertensive drugs, and the management of nonhypertensive patients. Long-term goal blood pressure in patients who have cerebrovascular disease is presented elsewhere. (See "Goal blood pressure in adults with hypertension", section on 'Prior history of ischemic stroke or transient ischemic attack'.) The diagnosis of stroke subtypes and risk factor reduction for the secondary prevention of stroke other than blood pressure control are discussed separately: (See "Clinical diagnosis of stroke subtypes".) (See "Overview of secondary prevention of ischemic stroke".) https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 1/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate TREATMENT IN THE ACUTE PHASE OF STROKE Treatment of hypertension may be an immediate concern in patients with acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. However, blood pressure management in the acute phase of stroke is different from chronic therapy. Acute blood pressure management is discussed in detail elsewhere for each of the major stroke types: (See "Initial assessment and management of acute stroke", section on 'Blood pressure management'.) (See "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis", section on 'Blood pressure management'.) (See "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis", section on 'Blood pressure control'.) The following sections provide a brief overview of blood pressure management in the acute phase of stroke, which necessarily transitions to decisions about long-term antihypertensive management. Who should be treated with pharmacologic therapy? Similar to American Heart Association (AHA) and American Stroke Association (ASA) guidelines, we recommend resumption of antihypertensive therapy for previously treated, neurologically stable patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events [3]. In addition, we recommend initiation of antihypertensive therapy for previously untreated, neurologically stable patients with any type of stroke or transient ischemic attack (TIA) who have an established blood pressure that is above goal ( table 1) [4]. When to initiate (or reinstate) antihypertensive therapy The appropriate time to initiate or reinstate antihypertensive drug therapy in hypertensive patients who have had a stroke or TIA can vary according to a number of factors, including stroke mechanism (eg, whether the stroke was ischemic or hemorrhagic), neurologic stability, and comorbid medical problems. Patients with transient ischemic attack In patients with a TIA, who by definition have recovered to their neurologic baseline and have no other evidence of infarction, we initiate (or reinstate) oral antihypertensive drug therapy without further delay. (See "Initial evaluation and management of transient ischemic attack and minor ischemic stroke".) Patients with ischemic stroke In patients with acute ischemic stroke, elevated blood pressures are typically tolerated (ie, "permissive hypertension") during the first 24 to 48 hours (the acute phase of an ischemic stroke) to theoretically augment cerebral blood flow https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 2/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate and reduce expansion of the ischemic infarct core. Exceptions that require treatment are patients with extreme hypertension (>220/120 mmHg), with other acute hypertension- related end-organ failure (eg, cardiac), patients with active ischemic coronary disease, patients with aortic dissection, patients with pre-eclampsia/eclampsia, and patients who are candidates for reperfusion therapy who have persistent blood pressure elevation greater than 185/110 mmHg. (See "Initial assessment and management of acute stroke", section on 'Blood pressure in acute ischemic stroke' and "Management of acute type B aortic dissection".) Beyond the acute period, we approach the time to start or resume antihypertensive medication as follows: For patients with hypertension who are neurologically improving or stable and able to safely swallow oral medications or receive them through a feeding tube, we initiate (or reinstate) antihypertensive drug therapy 24 to 48 hours after ischemic stroke onset and during hospitalization. For patients with hypertension who are neurologically unstable with fluctuating deficits or progressive deterioration, we delay starting or resuming antihypertensive drug therapy until the stroke-related deficits have stabilized or reached a nadir since blood pressure lowering may induce ischemic symptoms. This is discussed in detail separately. (See "Initial assessment and management of acute stroke", section on 'Blood pressure in acute ischemic stroke'.) Patients with intracerebral hemorrhage In patients with spontaneous intracerebral hemorrhage (ICH), there is often a need for intravenous antihypertensive treatment during the acute phase (see "Spontaneous intracerebral hemorrhage: Acute treatment and prognosis", section on 'Blood pressure management'). Intravenous antihypertensive therapy is then transitioned to oral therapy, when appropriate. Patients with subarachnoid hemorrhage In patients with subarachnoid hemorrhage, who are typically managed initially in the intensive care unit, antihypertensive therapy for secondary prevention is started if cerebral perfusion pressure is judged to be adequate, either by direct measurement or by an assessment of the patient's cognitive status. (See "Aneurysmal subarachnoid hemorrhage: Treatment and prognosis", section on 'Blood pressure control'.) MANAGEMENT AFTER THE ACUTE PHASE OF STROKE https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 3/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Selection of long-term antihypertensive medication In patients with a history of stroke or transient ischemic attack (TIA), antihypertensive therapy can prevent future strokes and cardiovascular death. The choice of drug is similar in patients who have had a previous stroke or TIA as in other hypertensive patients: Monotherapy is recommended when blood pressure is <20/10 mmHg above goal. Although the largest studies of secondary stroke prevention examined the effect of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and diuretics, there is no compelling evidence favoring one class of antihypertensive drugs over another as monotherapy for secondary prevention in such patients. ACE inhibitors, ARBs, calcium channel blockers, and diuretics are all reasonable options for initial antihypertensive monotherapy. (See "Choice of drug therapy in primary (essential) hypertension".) There is some evidence from clinical trials that beta blockers may not reduce stroke risk compared with angiotensin inhibitors (ACE inhibitor or ARB), calcium channel blockers, and, in some trials, placebo [5-7]. Thus, unless there is a compelling indication for their use, beta blockers should not be used as monotherapy for prevention of recurrent stroke. Combination therapy is recommended when blood pressure is 20/10 mmHg above goal. We use the combination of an angiotensin inhibitor plus a long-acting dihydropyridine calcium channel blocker among patients who should initiate therapy with two agents. This approach is consistent with our recommendations for other hypertensive patients who have not had a stroke or TIA. (See "Choice of drug therapy in primary (essential) hypertension".) In a meta-analysis of eight trials and more than 35,000 patients with a prior stroke or TIA, antihypertensive drug therapy reduced the rate of stroke (8.7 versus 10.1 percent) and cardiovascular death (4.0 versus 4.7 percent) [8]. There was also a nonsignificantly lower incidence of major adverse cardiovascular events (13.6 versus 15.1 percent). The largest studies included in this meta-analysis (the Perindopril Protection Against Recurrent Stroke Study [PROGRESS], Prevention Regimen for Effectively Avoiding Second Strokes [PRoFESS], and Post-stroke Antihypertensive Treatment Study [PATS] trials) examined ACE inhibitors, ARBs, and diuretics; therefore, many experts and the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend ACE inhibitors and diuretics for patients with prior stroke or TIA [4,9-11]. In several meta-analyses, however, the effects of calcium channel blockers were not statistically different from those of angiotensin inhibitors and diuretics [12-14]. In addition, among patients who require two antihypertensive https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 4/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate agents, a calcium channel blocker plus an ACE inhibitor (or ARB) is the ideal combination. (See "Choice of drug therapy in primary (essential) hypertension".) Goal blood pressure Patients with ischemic stroke or TIA and atherosclerotic disease The majority of patients who have had an ischemic stroke or transient ischemic attack (TIA) are at high risk for a future atherosclerotic cardiovascular event. Thus, in most such patients, we use a more intensive blood pressure goal, if tolerated ( table 1). Patients who become symptomatic with intensive blood pressure lowering may require a less intensive goal. Goal blood pressure in these higher-risk patients is discussed in detail elsewhere. (See "Goal blood pressure in adults with hypertension", section on 'Prior history of ischemic stroke or transient ischemic attack'.) Patients with ischemic stroke in the absence of atherosclerotic disease We do not consider a stroke or TIA that was caused by a cardioembolic phenomenon (eg, atrial fibrillation) or by a paradoxical embolus as evidence of atherosclerotic cardiovascular disease. Thus, in such patients who are not otherwise at high risk for a future atherosclerotic cardiovascular event, we use a less intensive goal blood pressure than we use for higher-risk patients ( table 1). Goal blood pressure in these lower-risk patients is discussed in detail elsewhere. (See "Goal blood pressure in adults with hypertension", section on 'Goal blood pressure in lower-risk patients'.) However, patients with cardioembolic stroke may have heart failure or other types of heart disease that would indicate lower blood pressure targets. Patients with intracerebral hemorrhage For prevention of recurrent intracerebral hemorrhage (ICH) in patients with spontaneous ICH, we suggest a more intensive blood pressure goal, similar to the goal in patients with ischemic stroke due to atherosclerotic disease ( table 1). In the PROGRESS trial, among the subgroup of 611 hypertensive patients with prior ICH, a modest reduction in blood pressure of 9/4 mmHg produced a 49 percent relative reduction in the risk for recurrent stroke (95% CI 18-68 percent) [15]. Post-hoc analyses found that the relationship of blood pressure lowering with reduced stroke risk was stronger for subjects with prior ICH than for those with prior ischemic stroke and that the lowest risk of recurrence was present in the patients with the lowest follow-up blood pressure levels [16]. (See "Spontaneous intracerebral hemorrhage: Secondary prevention and long-term prognosis", section on 'Blood pressure management'.) https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 5/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Patients with subarachnoid hemorrhage Hypertension is a major risk factor for subarachnoid hemorrhage. However, the optimal goal blood pressure for prevention of recurrent subarachnoid hemorrhage is unknown; for patients who are not otherwise at high risk for atherosclerotic cardiovascular events, a less intensive blood pressure goal as defined in the table is reasonable ( table 1). Rapidity by which goal is attained Gradual blood pressure reduction (eg, approximately 10 percent per day, although there is no consensus on the definition of gradual lowering) is recommended in patients with known cerebrovascular disease or long-standing uncontrolled hypertension unless there is a hypertensive emergency. The normal response to an acute reduction in blood pressure is to maintain tissue perfusion by autoregulatory precapillary vasodilation. Since flow is equal to pressure divided by resistance, parallel reductions in both parameters allow flow to be maintained. This response may be impaired in patients with chronic hypertension, including those who have not had a stroke. Persistent hypertension leads to arteriolar thickening. In the cerebral and other circulations, this is in part an appropriate adaptation in that it prevents the increase in pressure from being transmitted to the capillary circulation [17]. However, arteriolar thickening can also limit the ability to maintain perfusion when the blood pressure is lowered with antihypertensive therapy since the vasodilator response is often impaired. As a result, the lower blood pressure limit at which cerebral perfusion is maintained is higher in hypertensive than in normotensive subjects ( figure 1) [18]. In general, ischemic symptoms are not likely to occur unless the blood pressure is acutely reduced by more than 25 percent below the baseline level; gradual blood pressure reduction of approximately 10 percent per day is generally well tolerated. Gradual blood pressure reduction can be aided by home blood pressure monitoring. (See "Evaluation and treatment of hypertensive emergencies in adults" and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".) RECOMMENDATIONS OF OTHERS Guidelines for the prevention of recurrent stroke and transient ischemic attack (TIA) issued in 2021 by the American Stroke Association (ASA) and American Heart Association (AHA) recommend initiation of blood pressure therapy for previously untreated patients with ischemic stroke or TIA who, after the first few days (because blood pressure is typically elevated above baseline upon presentation), have an established blood pressure of 130 mmHg systolic or 80 https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 6/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate mmHg diastolic [19]. The guidelines also recommend resumption of blood pressure therapy 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 three days after stroke onset. The suggested goal blood pressure of <130/<80 mmHg is reasonable for secondary stroke prevention in all patients. European, Canadian, and Asian secondary stroke prevention guidelines have similar blood pressure goals as the United States guidelines [20]. For patients with intracerebral hemorrhage (ICH), 2022 guidelines from the AHA/ASA suggest a goal blood pressure of <130 mmHg systolic and <80 mmHg diastolic [21]. We generally agree with these recommendations, although our approach to goal blood pressure is more nuanced. (See "Goal blood pressure in adults with hypertension", section on 'Prior history of ischemic stroke or transient ischemic attack'.) SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Stroke (The Basics)" and "Patient education: Medicines after an ischemic stroke (The Basics)") https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 7/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Beyond the Basics topics (see "Patient education: Stroke symptoms and diagnosis (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Hypertension is a major risk factor for stroke and transient ischemic attack (TIA). The risk can be reduced by persistent correction of the hypertension. (See 'Introduction' above.) After the acute phase of stroke, antihypertensive therapy should be resumed in previously treated, neurologically stable patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events. In addition, antihypertensive therapy should be initiated in previously untreated, neurologically stable patients with any type of stroke or TIA who have an established blood pressure that is above goal ( table 1). (See 'Who should be treated with pharmacologic therapy?' above.) The appropriate time to initiate or reinstate antihypertensive drug therapy in hypertensive patients who have had a stroke or TIA varies (see 'When to initiate (or reinstate) antihypertensive therapy' above): In patients with a TIA, we initiate (or reinstate) oral antihypertensive drug therapy without further delay. For patients with acute ischemic stroke and hypertension who are neurologically improving or stable and able to safely swallow oral medications or receive them through a feeding tube, we initiate (or reinstate) antihypertensive drug therapy 24 to 48 hours after ischemic stroke onset and during hospitalization. For patients with hypertension who are neurologically unstable with fluctuating deficits or progressive deterioration, we delay starting or resuming antihypertensive drug therapy until the stroke-related deficits have stabilized or reached a nadir since blood pressure lowering may induce ischemic symptoms. In patients with spontaneous intracerebral hemorrhage (ICH), there is often a need for intravenous antihypertensive treatment during the acute phase. In patients with subarachnoid hemorrhage, antihypertensive therapy for secondary prevention is begun if cerebral perfusion pressure is judged to be adequate, either by direct measurement or by an assessment of the patient's cognitive status. The choice of drug is similar in patients who have had a previous stroke or TIA as in other hypertensive patients. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 8/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate receptor blockers (ARBs), calcium channel blockers, and diuretics are all reasonable options for initial antihypertensive monotherapy. (See 'Selection of long-term antihypertensive medication' above.) The majority of patients who have had an ischemic stroke or TIA are at high risk for a future atherosclerotic cardiovascular event. Thus, in most such patients, we use a more intensive blood pressure goal, if tolerated ( table 1). Patients who become symptomatic with intensive blood pressure lowering may require a less intensive goal. (See 'Patients with ischemic stroke or TIA and atherosclerotic disease' above.) We do not consider an ischemic stroke or TIA that was caused by a cardioembolic phenomenon (eg, atrial fibrillation) or by a paradoxical embolus as evidence of atherosclerotic cardiovascular disease. Thus, in such patients who are not otherwise at high risk for a future atherosclerotic cardiovascular event, we use a less intensive goal blood pressure than we use for higher-risk patients ( table 1). (See 'Patients with ischemic stroke in the absence of atherosclerotic disease' above.) For prevention of recurrent ICH in patients with spontaneous ICH, we suggest a more intensive blood pressure goal, similar to the goal in patients with ischemic stroke due to atherosclerotic disease ( table 1). (See 'Patients with intracerebral hemorrhage' above.) The optimal goal blood pressure for prevention of recurrent subarachnoid hemorrhage is unknown; for patients who are not otherwise at high risk for atherosclerotic cardiovascular events, a less intensive blood pressure goal as defined in the table is reasonable ( table 1). (See 'Patients with subarachnoid hemorrhage' above.) Gradual blood pressure reduction (eg, approximately 10 percent per day, although there is no consensus on the definition of gradual lowering) is recommended in patients with known cerebrovascular disease or long-standing uncontrolled hypertension unless there is a hypertensive emergency. (See 'Rapidity by which goal is attained' above.) ACKNOWLEDGMENT The editorial staff at UpToDate acknowledge Norman M Kaplan, MD, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 9/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate 1. Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903. 2. Messerli FH, Bangalore S. Blood pressure and stroke: findings from recent trials. J Am Coll Cardiol 2011; 57:114. 3. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160. 4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13. 5. Wiysonge CS, Bradley H, Mayosi BM, et al. Beta-blockers for hypertension. Cochrane Database Syst Rev 2007; :CD002003. 6. Bangalore S, Parkar S, Grossman E, Messerli FH. A meta-analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new-onset diabetes mellitus. Am J Cardiol 2007; 100:1254. 7. Bangalore S, Wild D, Parkar S, et al. Beta-blockers for primary prevention of heart failure in patients with hypertension insights from a meta-analysis. J Am Coll Cardiol 2008; 52:1062. 8. Zonneveld TP, Richard E, Vergouwen MD, et al. Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev 2018; 7:CD007858. 9. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure- lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358:1033. 10. Yusuf S, Diener HC, Sacco RL, et al. Telmisartan to prevent recurrent stroke and cardiovascular events. N Engl J Med 2008; 359:1225. 11. Liu L, Wang Z, Gong L, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res 2009; 32:1032. 12. Lee M, Saver JL, Hong KS, et al. Renin-Angiotensin system modulators modestly reduce vascular risk in persons with prior stroke. Stroke 2012; 43:113. https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 10/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate 13. Chen GJ, Yang MS. The effects of calcium channel blockers in the prevention of stroke in adults with hypertension: a meta-analysis of data from 273,543 participants in 31 randomized controlled trials. PLoS One 2013; 8:e57854. 14. Wang WT, You LK, Chiang CE, et al. Comparative Effectiveness of Blood Pressure-lowering Drugs in Patients who have Already Suffered From Stroke: Traditional and Bayesian Network Meta-analysis of Randomized Trials. Medicine (Baltimore) 2016; 95:e3302. 15. Chapman N, Huxley R, Anderson C, et al. Effects of a perindopril-based blood pressure- lowering regimen on the risk of recurrent stroke according to stroke subtype and medical history: the PROGRESS Trial. Stroke 2004; 35:116. 16. Arima H, Chalmers J, Woodward M, et al. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens 2006; 24:1201. 17. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke 2003; 34:2741. 18. Strandgaard S, Olesen J, Skinhoj E, Lassen NA. Autoregulation of brain circulation in severe arterial hypertension. Br Med J 1973; 1:507. 19. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364. 20. McGurgan IJ, Kelly PJ, Turan TN, Rothwell PM. Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke. Stroke 2022; 53:1085. 21. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282. Topic 3823 Version 40.0 https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 11/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate GRAPHICS Goal blood pressure according to baseline risk for cardiovascular disease and method of measuring blood pressure Routine/conventional office blood pressure Unattended AOBPM, (manual measurement daytime ABPM, or home with stethoscope or oscillometric device)* blood pressure Higher-risk population 125 to 130/<80 120 to 125/<80 Known ASCVD Heart failure Diabetes mellitus Chronic kidney disease Age 65 years Calculated 10-year risk of ASCVD event 10% Lower-risk 130 to 139/<90 125 to 135/<90 None of the above risk factors All target ranges presented above are in mmHg. On average, blood pressure readings are 5 to 10 mmHg lower with digital, unattended, or out-of- office methods of measurement (ie, AOBPM, daytime ABPM, home blood pressure) than with routine/standard methods of office measurement (ie, manual auscultatory or oscillometric measurement), presumably due to the "white coat effect." However, it is critical to realize that this average difference in blood pressures according to the methodology of measurement applies to the population and not the individual. Some patients do not experience a white coat effect, and, therefore, there is some uncertainty in setting goals that are specific to the method of measurement. When treating to these goals, a patient may (inadvertently) attain a blood pressure below the given target. Provided the patient does not develop symptoms, side effects, or adverse events as a result of the treatment regimen, then reducing or withdrawing antihypertensive medications is unnecessary. Less aggressive goals than those presented in the table may be appropriate for specific groups of patients, including those with postural hypotension, the frail older adult patient, and those with side effects to multiple antihypertensive medications. https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 12/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate AOBPM: automated oscillometric blood pressure monitoring; ABPM: ambulatory blood pressure monitoring; ASCVD: atherosclerotic cardiovascular disease; ACC/AHA: American College of Cardiology/American Heart Association. Office blood pressure must be performed adequately in order to use such measurements to manage patients. Critical to an adequate office assessment of blood pressure are proper patient positioning (eg, seated in a chair, feet flat on the floor, arm supported, remove clothing covering the location of cuff placement) and proper technique (eg, calibrated device, proper-sized cuff). The average of multiple measurements should be used for management. Refer to UpToDate topics on measurement of blood pressure. Office readings should not be used to manage blood pressure unless it is performed adequately. Home blood pressure, like office blood pressure, must be performed adequately in order for the measurements to be used to manage patients. First, the accuracy of the home blood pressure device must be verified in the clinician's office. Second, the clinician should verify that the cuff and bladder that the patient will use are the appropriate size. Third, patients should measure their pressure after several minutes of rest and while seated in a chair (back supported and feet flat on the floor) with their arm supported (eg, resting on a table). Fourth, the blood pressure should be measured at different times per day and over multiple days. The average value of these multiple measurements is used for management. Home blood pressure readings should not be used to manage blood pressure unless it is performed adequately and in conjunction with office blood pressure or ambulatory blood pressure. The level of evidence supporting the lower goal in higher-risk individuals is stronger for some risk groups (eg, patients with known coronary heart disease, patients with a calculated 10-year risk 15%, chronic kidney disease) than for other risk groups (eg, patients with diabetes, patients with a prior stroke). Refer to UpToDate topics on goal blood pressure for a discussion of the evidence. Prior history of coronary heart disease (acute coronary syndrome or stable angina), prior stroke or transient ischemic attack, prior history of peripheral artery disease. In older adults with severe frailty, dementia, and/or a limited life expectancy, or in patients who are nonambulatory or institutionalized (eg, reside in a skilled nursing facility), we individualize goals and share decision-making with the patient, relatives, and caretakers, rather than targeting one of the blood pressure goals in the table. The 2013 ACC/AHA cardiovascular risk assessment calculator should be used to estimate 10-year cardiovascular disease risk. In the large subgroup of patients who have an initial (pretreatment) blood pressure 140/ 90 mmHg, but who do not have any of the other listed cardiovascular risk factors, some experts would set a more aggressive blood pressure goal of <130/<80 mmHg rather than those presented in the table. This more aggressive goal would likely reduce the chance of developing severe hypertension and ultimately lower the relative risk of cardiovascular events in these lower-risk patients over the long term. However, the absolute benefit of more aggressive blood pressure lowering in these patients is comparatively small, and a lower goal would require more intensive pharmacologic therapy and corresponding side effects. Graphic 117101 Version 3.0 https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 13/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Cerebral autoregulation in hypertension Schematic representation of autoregulation of cerebral blood flow in normotensive and hypertensive subjects. In both groups, initial increases or decreases in mean arterial pressure are associated with maintenance of cerebral blood flow due to appropriate changes in arteriolar resistance. More marked changes in pressure are eventually associated with loss of autoregulation, leading to a reduction (with hypotension) or an elevation (with marked hypertension) in cerebral blood flow. These changes occur at higher pressures in patients with hypertension, presumably due to arteriolar thickening. Thus, aggressive antihypertensive therapy will produce cerebral ischemia at a higher mean arterial pressure in patients with underlying hypertension. Redrawn from: Kaplan NM. Management of hypertensive emergencies. Lancet 1994; 344:1335. Based on data from: Strandgaard S, Paulson OB. Cerebral blood ow and its pathophysiology in hypertension. Am J Hypertens 1989; 2:486. Graphic 57676 Version 5.0 https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 14/15 7/6/23, 12:38 PM Antihypertensive therapy for secondary stroke prevention - UpToDate Contributor Disclosures Raymond R Townsend, MD Consultant/Advisory Boards: Backbeat [Hypertension]; BD [Hypertension]; Janssen [Hypertension]; Medtronic [Hypertension]. All of the relevant financial relationships listed have been mitigated. Natalia S Rost, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Adam de Havenon, MD, MS Equity Ownership/Stock Options: Certus Critical Care [Stroke treatment]; TitinKM [Shoulder rehabilitation]. Consultant/Advisory Boards: Integra [Intracranial ventricular drain]; NovoNordisk [Diabetes]. All of the relevant financial relationships listed have been mitigated. George L Bakris, MD Grant/Research/Clinical Trial Support: Bayer [Diabetic nephropathy]; KBP Biosciences [Resistant hypertension]; Novo Nordisk [Diabetic kidney disease]. Consultant/Advisory Boards: Alnylam [Resistant hypertension]; AstraZeneca [Diabetic nephropathy]; Bayer [Nephropathy]; Ionis [Resistant hypertension]; KBP BioSciences [Resistant hypertension]; Vifor [Hyperkalemia]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John P Forman, MD, MSc No relevant financial relationship(s) with ineligible companies to disclose. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/antihypertensive-therapy-for-secondary-stroke-prevention/print 15/15