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Stroke and transient ischaemic attack - Management
What blood pressure lowering treatment is recommended for someone who has had a stroke or TIA?

  • All people with stroke or transient ischaemic attack (TIA) should have their blood pressure checked and be offered antihypertensive treatment in line with national guidelines:
    • For people with a TIA: consider starting antihypertensive treatment as soon as possible.
    • For people with an acute stroke: treatment will usually be initiated in secondary care about 2 weeks after the event (unless a hypertensive emergency requires urgent reduction in blood pressure).
  • Optimal target blood pressure:
    • For people with established cardiovascular disease: aim to reduce blood pressure to 140/90 mmHg or less, and preferably to 130/80 mmHg.
    • For people with bilateral, severe (more than 70%) stenosis of the internal carotid arteries a slightly higher target blood pressure (e.g. systolic blood pressure 150 mmHg) may be appropriate.
    • For information and prescription details, see the CKS topic on Hypertension - not diabetic for people without Type 2 diabetes; otherwise, see the CKS topic on Diabetes type 2.
Basis for recommendation
  • These recommendations are in line with guidance issued by the National Institute for Health and Clinical Excellence (NICE), the Royal College of Physicians Intercollegiate Stroke Working Party (RCP ICSWP), and the Department of Health [DH, 2007; Intercollegiate Stroke Working Party, 2008; National Collaborating Centre for Chronic Conditions, 2008].
  • When to start antihypertensive treatment:
    • NICE found no evidence to suggest that manipulating blood pressure in acute stroke (within the first 72 hours) using beta-blockers or calcium-channel antagonists, compared with control or placebo, had any beneficial effect on mortality, dependency, or stroke recurrence. Because there are also concerns about possible adverse effects with early reduction in blood pressure, NICE recommends starting antihypertensive treatment in people with acute stroke only if there is a hypertensive emergency.
    • Experts suggested that waiting about 2 weeks before starting treatment would be reasonable [Sudlow, 2008].
  • Blood pressure targets:
    • The recommended blood pressure targets reflect national guidelines and expert opinion.
    • NICE recommends a target blood pressure of 140/90 mmHg or less for people with existing cardiovascular disease or target organ damage [NICE, 2006]. This is consistent with the National Stroke Strategy, which recommends a systolic blood pressure less than 140 mmHg for prevention [DH, 2007].
    • For secondary prevention of stroke, the RCP ICSWP guideline recommends a blood pressure target of 130/80 mmHg based on recommendations issued by the Joint British Hypertension Society [BHS, 2004; Intercollegiate Stroke Working Party, 2008]. This blood pressure target is also advocated by the Joint British Societies guideline [British Cardiac Society et al, 2005].
    • A higher target blood pressure (e.g. systolic blood pressure of 150 mmHg) for people with bilateral severe carotid artery stenosis is recommended by the RCP ICSWP guidelines [Intercollegiate Stroke Working Party, 2008]. No evidence suggests that people with severe stenosis should have a systolic blood pressure more than 150 mmHg.
    • The RCP ICSWP report acknowledged that there is little research into the relationship between blood pressure and risk of recurrent stroke [Intercollegiate Stroke Working Party, 2008]. However, the report highlights that there is research on the effects of lowering blood pressure on the risk of further strokes and other acute vascular events.

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