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cardio.hypertensive-emergency.post-stroke.v1

Hypertensive emergency in acute ischemic stroke (autoregulation-aware BP target by reperfusion eligibility)

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Phase E variant of cardio.hypertensive-emergency.core.v1 — narrowed to BP management in acute ischemic stroke. Cerebral autoregulation impaired; BP target depends on reperfusion eligibility (lytic <185/110 pre-bolus then <180/105 × 24 h; thrombectomy 140-180 pre-procedure; permissive >220 or >120 if not eligible). Drug profile: nicardipine first-line; labetalol second-line; norepinephrine rescue if SBP <140 pre-thrombectomy. AVOID nitroprusside (cerebral vasodilation + ICP), AVOID hydralazine (unpredictable overshoot). Routes to neuro.ischaemic-stroke.v1 for stroke-specific management; ICH on imaging routes to neuro.ich.core.v1. Manifest pointer reuses cardio.hypertensive-emergency.core.v1 manifest. Design-brief pointer reuses parent (post-stroke-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as part of HTN emergency Phase E variant batch.

Entry points (3)

  • symptom
    Acute focal neuro deficit (NIHSS ≥1) + SBP ≥185 OR DBP ≥110 — pre-lytic BP lowering window (AHA/ASA 2024 PMID 38483443)
    acute_focal_neuro_deficit_with_severe_HTN
  • imaging
    CT/MRI confirms acute ischemic stroke (no hemorrhage) + BP elevation requiring management per reperfusion eligibility
    ct_or_mri_acute_ischemic_stroke
  • history
    Large vessel occlusion (LVO) confirmed on CTA + thrombectomy candidate + BP lowering needed pre-procedure to keep SBP 140-180 (BP-TARGET PMID 32569748)
    lvo_thrombectomy_candidate_with_HTN

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Older patients have rightward-shifted cerebral autoregulation; precipitous BP drop risks penumbral hypoperfusion (AHA/ASA 2024)
  • sbprequired
    vital • used at RED_FLAGS
    Defines pre-lytic threshold (<185), thrombectomy-window threshold (140-180), and permissive-HTN threshold (>220) per AHA/ASA 2024 PMID 38483443
  • dbprequired
    vital • used at RED_FLAGS
    Pre-lytic threshold <110 (AHA/ASA 2024); component of MAP for reperfusion-window monitoring
  • nihss_scorerequired
    symptom • used at RED_FLAGS
    Stroke severity drives reperfusion eligibility + BP target band (NIHSS 6-25 with LVO + ASPECTS ≥6 = thrombectomy band)
  • last_known_well_timerequired
    symptom • used at CONTEXT
    Drives lytic window (≤4.5 h alteplase / ≤4.5 h tenecteplase) + thrombectomy window (≤24 h with imaging selection per DAWN/DEFUSE-3); BP target follows reperfusion eligibility
  • ct_head_nonconrequired
    imaging • used at INITIAL_WORKUP
    Mandatory before BP lowering — exclude ICH (which has different SBP target per INTERACT-3 PMID 37004949 + AHA/ASA 2022 ICH guideline); confirm ischemic stroke
  • cta_head_neckrequired
    imaging • used at INITIAL_WORKUP
    Identify LVO → drives thrombectomy decision → drives 140-180 SBP band pre-procedure
  • serial_ct_for_hemorrhagic_conversionrequired
    imaging • used at MONITORING
    Serial CT at 24 h post-lytic (or sooner if neuro decline) — hemorrhagic conversion shifts BP target downward to ICH band
  • creatininerequired
    lab • used at INITIAL_WORKUP
    eGFR drives nicardipine vs nitroprusside selection (cyanide if eGFR <30 + duration); also iodinated contrast risk for CTA
  • inr_and_plateletsrequired
    lab • used at INITIAL_WORKUP
    INR + platelets gate alteplase eligibility (INR ≤1.7, platelets ≥100k); also drive ICH-risk stratification post-lytic

12-phase flow (10)

  1. 1FRAME
    Hypertensive emergency in acute ischemic stroke — cerebral autoregulation impaired; BP target depends on reperfusion eligibility (lytic <185/110 pre-bolus, thrombectomy 140-180 pre-procedure, ineligible permissive >220 or >120). AVOID precipitous drop (penumbral hypoperfusion). Distinguish from ICH (lower target 130-140 per INTERACT-3 PMID 37004949). Route to parent engine for shared HTN-emergency arc + neuro.ischaemic-stroke.v1 for stroke-specific management; this dossier owns reperfusion-band-specific BP titration.
    inputs: sbp, dbp, nihss_score, last_known_well_time
    advance: reperfusion eligibility band determined + ICH excluded on CT
  2. 2ENTRY
    Recognize acute ischemic stroke + severe HTN; STAT CT head non-con FIRST to exclude ICH before any BP lowering decision
    inputs: age, sbp, last_known_well_time
    advance: CT head obtained
  3. 3CONTEXT
    Last known well time, anticoagulant exposure (DOAC reversal options), prior stroke (re-bleed risk if AC), chronic HTN duration (autoregulation shift), antihypertensive history, atrial fibrillation (cardioembolic stroke needs anticoagulation post-stroke); sympathomimetic exposure (cocaine — different pathway)
    inputs: age
    advance: context complete; thrombolysis + thrombectomy eligibility screened
  4. 4RED_FLAGS
    Coma / GCS <8 → intubation + cooperate with stroke team; rapid neuro decline during titration → re-image + slow titration; new ICH on serial CT → switch to ICH band (130-140 per INTERACT-3); status epilepticus → benzo + AED
    inputs: sbp, dbp, nihss_score
    actions: htn_emergency
    advance: RED flags screened + airway plan documented + reperfusion timeline anchored
  5. 5INITIAL_WORKUP
    CT head non-con (mandatory), CTA head/neck for LVO, BMP + INR + platelets + glucose, ECG (AF screen), troponin (cardio-stroke overlap), lipid + A1c for secondary prevention, β-hCG if reproductive-age
    inputs: creatinine, inr_and_platelets, ct_head_noncon, cta_head_neck
    actions: panel.cardiac, panel.renal
    advance: workup documented + ICH excluded + LVO confirmed/excluded
  6. 6BRANCHING_WORKUP
    CT/MR perfusion if extended-window thrombectomy candidate (4.5-24 h per DAWN/DEFUSE-3); echo for cardioembolic source; carotid US/CTA for ICA stenosis; 24 h Holter for AF post-discharge
    advance: reperfusion decision + secondary-prevention workup launched
  7. 7TREATMENT
    BP lowering follows reperfusion band: PRE-LYTIC: nicardipine 5 mg/h (titrate q5-15 min) OR labetalol 10-20 mg IV q10 min to SBP <185, DBP <110 → administer alteplase/TNK → maintain <180/105 × 24 h post-lytic. PRE-THROMBECTOMY: maintain SBP 140-180 — nicardipine titrate down if >180, vasopressor (NE) UP if <140 (penumbral perfusion preservation per BP-TARGET PMID 32569748 + ENCHANTED PMID 27067691). NOT-ELIGIBLE: permissive HTN; treat only if SBP >220 OR DBP >120 OR end-organ damage; gentle MAP reduction ≤15% in first 24 h. POST-RECANALIZATION: emerging consensus is more aggressive lowering after successful TICI 2b-3 reperfusion (target SBP 120-140 per ENCHANTED-2 / OPTIMAL-BP) but the BP-TARGET trial signal of harm with intensive lowering keeps the field cautious — individualize. AVOID nitroprusside (cerebral vasodilation, ICP rise); AVOID hydralazine (unpredictable overshoot).
    inputs: sbp, dbp, creatinine, inr_and_platelets
    advance: IV agent titrated to band-specific target; reperfusion delivered or band-confirmed permissive
  8. 8DISPOSITION
    Stroke unit / Neuro-ICU for q5-15 min BP + q15 min neuro exam during reperfusion window; arterial line; intubation if GCS <8 or post-thrombectomy general anesthesia; routes to neuro.ischaemic-stroke.v1 for stroke-specific management
    advance: Stroke unit / Neuro-ICU bed assigned + neuro team co-managing
  9. 9MONITORING
    A-line + q5-15 min BP × 24 h post-lytic / post-thrombectomy; q15-30 min neuro exam during first 6 h; serial CT at 24 h to detect hemorrhagic conversion (or sooner if neuro decline); daily BMP for AKI; HD-NIHSS at 24 h
    inputs: sbp, serial_ct_for_hemorrhagic_conversion
    actions: panel.renal
    advance: BP at band-target × 24 h + no hemorrhagic conversion + neuro stable or improving
  10. 10FOLLOWUP
    Transition to oral 4-tier ladder by 24-48 h once stable; outpatient SBP target <130 per SPRINT (PMID 26551272) for secondary stroke prevention; secondary-prevention bundle (statin, antiplatelet, AC if cardioembolic per CHA2DS2-VASc); cardiac rehab if appropriate; BP at home <130/80
    advance: oral regimen stable + outpatient stroke follow-up booked + 2nd-prevention bundle established