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Approach to elevated blood pressure in acute ischemic stroke
Blood pressure level (mm Hg) Treatment
A. Not eligible for thrombolytic therapy
Systolic <220 OR Diastolic <120
  • Observe unless other end-organ involvement, eg, aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive encephalopathy
  • Treat other symptoms of stroke such as headache, pain, agitation, nausea, and vomiting
  • Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia
Systolic >220 OR Diastolic 121-140
  • Labetalol 10-20 mg IV over 1-2 min. May repeat or double every 10 min (maximum dose 300 mg or
  • Nicardipine 5 mg/hr IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/hr every 5 min to maximum of 15 mg/hr
  • Aim for a 10 percent to 15 percent reduction of blood pressure
Diastolic >140
  • Nitroprusside 0.5 mcg/kg/min IV infusion as initial dose with continuous blood pressure monitoring
  • Aim for a 10 percent to 15 percent reduction of blood pressure
B. Eligible for thrombolytic therapy
Pretreatment
Systolic >185 OR Diastolic >110
  • Labetalol 10-20 mg IV over 1-2 min
  • May repeat x 1 OR nitropaste 1-2 inches
During and after treatment
1. Monitor BP Check BP every 15 min for 2 hours, then every 30 min for 6 hours, and then every hour for 16 hours
2. Diastolic >140 Sodium nitroprusside 0.5 µg/kg/min IV infusion as initial dose and titrate to desired blood pressure
3. Systolic >230 OR Diastolic 121-140
  • Labetalol 10 mg IV over 1-2 min
  • May repeat or double labetalol every 10 min to a maximum dose of 300 mg or give the initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min    or
  • Nicardipine 5 mg/hr IV infusion as initial dose;
  • Titrate to desired effect by increasing 2.5 mg/hr every 5 min to maximum of 15 mg/hr. If BP is not controlled by labetalol, consider sodium nitroprusside
4. Systolic 180-230 OR Diastolic 105-120
  • Labetalol 10 mg IV over 1-2 min
  • May repeat or double labetalol every 10 to 20 min to a maximum dose of 300 mg or give the initial labetalol bolus and then start drip at 2 to 8 mg/min
 *Si existe contraindicación de Labealol utilizar Enalapril 1 mg  o Urapidilo 25 mg

Reproduced with permission from: Adams, HP Jr, Adams, RJ, Brott, T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association, Stroke 2003; 34:1056. Copyright © 2003 Lippincott Williams and Wilkins.


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