Hypertension is among the most important risk factors for the occurrence of stroke. Acute stroke patients commonly have an elevated blood pressure (BP), and maintaining an appropriate level of BP is a crucial step in the successful management of acute stroke. In this article, we review various trial and published guidelines for the management of hypertension during intracerebral hemorrhage (ICH) and acute ischemic stroke. Patients with ICH were found to have systolic BP (SBP) in the range of 150 to 220 mm Hg and need acute lowering of SBP to less than 140 mm Hg. It is safe to do so if there are no contraindications. If a patient with ICH presents with an SBP of more than 220 mm Hg, then the BP should be lowered aggressively using intravenous infusion along with frequent monitoring. Patients of acute ischemic stroke, who have BP >185/110 mm Hg, should have their BP rapidly controlled, if they are being considered for thrombolytic therapy. Injectable labetalol, nicardipine, hydralinzine, and enalaprilat are considered appropriate for acute management of elevated BP in patients with acute ischemic stroke. Patients of acute ischemic stroke with SBP > 180 to 230 mm Hg or diastolic BP (DBP) > 105 to 120 mm Hg should receive intravenous labetalol 10 mg; this can be followed by a continuous infusion at the rate of 2 to 8 mg/min, if required. Nicardipine infusion is another alternative that can be uptitrated according to the desired BP levels. For secondary prevention of ischemic stroke, BP lowering can be done after first several days. The SBP > 140 mm Hg and DBP >90 mm Hg should be treated.
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