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What are Conditions to Stop Antihypertensive in Acute Stroke?

This article will discuss the effectiveness of continuing and stopping Antihypertensive in acute stroke patients, and if it can be stopped in what conditions and when is the right time to do it.

High blood pressure or hypertension is often comorbid from acute stroke cases. The administration of antihypertensive drugs in treating acute stroke is usually done to reduce blood pressure. However, there are no studies that assess when the right time to stop giving these antihypertensive drugs to patients with post-stroke.

Approximately 50% of patients who present with an acute stroke have taken oral antihypertensive drugs previously, both as a treatment to control blood pressure and therapy for other diseases such as ischemic heart disease, heart failure, and atrial fibrillation.

Significant blood pressure increases are common in acute stroke patients (onset <48 hours). Increased blood pressure can occur in patients who indeed suffer from hypertension or who previously had normal blood pressure.

Increased blood pressure in acute stroke is due to increased sympathetic nerve activity, response to cerebral ischemia, increased intracranial pressure, impaired baroreceptor sensitivity, and impaired autonomic regulation. High blood pressure in acute stroke cases is associated with a worse prognosis.

In the acute phase of stroke, sometimes blood pressure decreases spontaneously without antihypertensive medication within 24 hours. Spontaneous blood pressure decrease in acute stroke is common in the 4th day until the 10th day after onset.

Therefore, whether oral antihypertensive drugs need to be continued in the acute phase of stroke, even though the disease progresses, blood pressure usually decreases spontaneously.

During an acute stroke attack, patients often experience a decrease in consciousness and dysphagia, making it difficult to administer drugs orally, so it is doubtful to continue the patient's antihypertensive therapy.


Management of Blood Pressure in Acute Stroke

Management of blood pressure in acute stroke cases is a dilemma because blood pressure that is too low reduces perfusion to brain tissue, thereby expanding tissue infarction or ischemia perihematomal.

On the other hand, too high blood pressure can cause cerebral edema and increase the bleeding risk that widens the hematoma. Either high blood pressure or too low blood pressure can both worsen the prognosis of acute stroke patients.

Based on the 2013 AHA guidelines, there has not been an ideal blood pressure determination in acute ischemic stroke management. The guidelines currently available suggest that active management reduces blood pressure when the blood pressure of acute stroke patients exceeds 220 mmHg (systole) or 120 mmHg (diastole).

Mean arterial pressure (MAP), which is still between 50-150 mmHg, ensures adequate cerebral autoregulation. Increased blood pressure> 220/120 mmHg increases MAP> 150 mmHg associated with hyperperfusion syndrome or hemorrhagic transformation in stroke patients' ischemic brain tissue.

Criteria for patients who do not need active management to reduce blood pressure:

  • Patients who do not meet the criteria for thrombolytic therapy with a tissue Plasminogen Activator (tPA) and have blood pressure <220 mmHg (systole) and <120 mmHg (diastole)
  • No signs of target organ damage (hypertensive encephalopathy, pulmonary edema, or aortic dissection)


Blood pressure must be continuously monitored, and management takes precedence over stroke complications such as increased intracranial pressure or seizures.

If the patient meets the indications and is planned for intravenous thrombolytic tPA,

  • the patient's blood pressure needs to be lowered to <185 mmHg (systole) and <110 mmHg (diastole) before the procedure.
  • Blood pressure below 185/105 mmHg is maintained 24 hours post-action to reduce the risk of intracerebral hemorrhage.
  • Patients who will receive intra-arterial recanalization therapy need to lower their blood pressure to <180/105 mmHg.


In patients with ischemic stroke who are undergoing endovascular thrombectomy, decreased blood pressure is associated with poorer therapeutic outcomes. Therefore blood pressure should be lowered after a successful reperfusion action, with a reduction in the limit to 120-140 mmHg (systole).

In hemorrhagic stroke cases, aggressive blood pressure reduction can be more tolerated with a lower risk of neurological symptoms. Several studies showed that a decrease in blood pressure is sufficient if it reaches a systolic pressure of 140 mmHg. A reduction in blood pressure below 140 mmHg does not provide benefits. If the blood pressure is too low, it can increase the risk of complications of kidney disorders.



Why Stop Antihypertension in the Acute Stroke Phase?

The reasons for stopping antihypertension in the acute phase of stroke are the patient has decreased consciousness and impaired oral intake due to dysphagia. These conditions are related to an increase in the incidence of aspiration pneumonia when administering antihypertensive drugs orally.

Some antihypertension drugs, such as ARB, calcium channel blockers, and nitric oxide, have neuroprotective effects in acute stroke.

However, some types of antihypertension in the acute phase can cause hypotension and decreased cardiac output. These conditions worsen the cerebral hypoperfusion due to cerebral autoregulation dysfunction.

Hypertension is a risk factor that can be modified in stroke patients. Hypertension in stroke patients is associated with a worse long-term prognosis, characterized by an increased incidence of recurrent stroke, disability, and premature death several months after stroke onset.

Based on this, continuing antihypertensive administration should be more beneficial to prevent rebounding elevated blood pressure and secondary prevention of recurrent stroke.

On the other hand, the temporary cessation of antihypertension in acute stroke patients can provide benefits, namely increasing blood flow through collateral vessels and reducing the risk of aspiration due to oral drug administration.

Acute stroke patients often experience hypovolemia. Due to reduced oral intake, the administration of antihypertensive conditions will worsen the patient's condition.

Antihypertension is needed in long-term therapy after stroke as recurrent stroke prevention. However, the effectiveness of continuing antihypertension in the acute phase of stroke has not shown clear benefits.

Studies on administering antihypertensives to control blood pressure in acute stroke patients show neutral results.



The effects of stopping or continuing antihypertension in acute stroke patients

Two randomized controlled studies examine the effect of stopping or continuing transient antihypertensive (> 7 days) in acute stroke patients.

A study of The Continue or Stop Post-Stroke Antihypertensives Collaborative Study included 763 acute stroke patients divided into 2 groups. The first group was to continue the patient's antihypertensive treatment. In contrast, the second group was stopped antihypertensive patients for 2 weeks.

At the observation after 2 weeks, there were no significant differences in the primary outcome in terms of mortality and patient dependencies (based on the modified Rankin Scale) in the two groups.
The antihypertensive group found lower blood pressure than the group who did not get antihypertension (mean difference systole 13 and diastole 8 mmHg). Observations after 6 months also showed no significant differences in mortality, cardiovascular disorders, and severe complications between the two groups.

Efficacy of Nitric Oxide in Stroke study of 4011 patients with a history of acute stroke in the last 48 hours and systolic blood pressure between 140-220 mmHg, randomly divided into 2 groups given glyceryl trinitrate patch and not given.

2097 patients that previously have taken antihypertensive drugs were divided into 2 groups. The first group was continuing antihypertensive drugs, and the second group was asked to stop using it for 7 days.

There was no significant difference in the primary outcome of the patient's disability (dependency) (assessed by the modified Rankin Scale) on observations of the 90th day after randomization (continuing vs. stopping antihypertension). A decrease in blood pressure was found in both groups, either with continued or stopped antihypertensive drugs.

The secondary outcome of the ENOS study showed that in the group of patients who continued their antihypertensive drugs, there was an increase in cognitive impairment, worse disability and an increased risk of pneumonia on the 90th day of observation. However, these findings can not be ascertained due to the effects of antihypertensive given or due to other factors.

A study studied a group of patients from previous ENOS studies. Of the 629 sample patients with hemorrhagic stroke and systolic blood pressure between 140-220 mmHg, 246 patients who had previously taken antihypertension were divided into 2 groups.

The first group continued to take antihypertensive. And in the second group, antihypertensive was stopped temporarily for 7 days. The primary outcome observed was patient dependency based on the modified Rankin Scale on day 90. Secondary outcomes are mortality, length of hospital stay, daily activities, mood, cognitive, quality of life of patients, and severe complications.

Of these 246 patients, both groups experienced a decrease in blood pressure. Blood pressure in the group given antihypertension was significantly lower than not given antihypertension (difference of 9.4 / 3.5 mmHg, P <0.01).

Significant differences in blood pressure between the two groups began to be observed on the 5th day. On the 90th day, there were no significant differences in patient dependencies based on modified Rankin Scale scores or secondary outcomes in the two treatment groups. So that researchers concluded that in hemorrhagic stroke cases, continuing antihypertension in the acute phase (during the first 7 days) did not significantly reduce mortality or disability rate compared to temporarily stopping antihypertensive treatment of patients.

The American Heart Association (AHA) conducted a meta-analysis of the results of the COSSACS and ENOS studies above and found no significant association between antihypertensive administration followed by a risk of death or dependency follow-up compared to the cessation of antihypertension in the acute stroke phase.

The study revealed that continuing antihypertensive treatment did not provide significant benefits in the treatment of acute stroke. Antihypertension does not need to be given immediately or in a hurry, especially a few hours or days after a stroke unless there is an indication of antihypertension for comorbid patients.

The same study also reported a significant decrease in blood pressure in patients who continued antihypertensive compared to patients whose antihypertensive medication was stopped for 1 week. On the 7th day of observation, the difference in systole pressure was 9.4 mmHg, and diastole 5.1 mmHg was lower in the group receiving antihypertensive drugs—however, an analysis of the short and long term effects of continuing action.

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