This handout is for hypertensive emergency in acute ischemic stroke (autoregulation-aware bp target by reperfusion eligibility). Your care team identified this based on: acute focal neuro deficit (nihss ≥1) + sbp ≥185 or dbp ≥110 — pre-lytic bp lowering window (aha/asa 2024 pmid 38483443).
Other reasons your team may use this plan: ct/mri confirms acute ischemic stroke (no hemorrhage) + bp elevation requiring management per reperfusion eligibility; large vessel occlusion (lvo) confirmed on cta + thrombectomy candidate + bp lowering needed pre-procedure to keep sbp 140-180 (bp-target pmid 32569748).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| nicardipine | 5 mg/h IV, titrate by 2.5 mg/h q5-15 min, max 15 mg/h | IV | continuous | AHA/ASA 2024 PMID 38483443 first-line — predictable titration; no cerebral vasodilation harm; preferred over labetalol for fine titration during reperfusion window |
| labetalol | 10-20 mg IV q10 min (max 300 mg cumulative) OR 0.5-2 mg/min infusion | IV | bolus or infusion | AHA/ASA 2024 second-line — useful when sympathetic drive high; mixed α/β; no reflex tachycardia; bolus easier than infusion in busy ED |
| clevidipine | 1-2 mg/h IV, titrate q90 sec | IV | continuous | Ultra-short half-life allows minute-to-minute titration during thrombectomy window; lipid emulsion (avoid egg/soy allergy) |
| norepinephrine | 0.05-0.5 mcg/kg/min IV, titrate to SBP ≥140 | IV | continuous | BP-TARGET PMID 32569748 + ENCHANTED PMID 27067691 — penumbral perfusion preservation requires SBP ≥140 pre-thrombectomy; vasopressor support if BP drops too far |
| AVOID nitroprusside | AVOID | N/A | N/A | Cerebral vasodilation worsens ICP; cyanide risk if eGFR <30 + duration >24 h; AHA/ASA 2024 AVOID in acute stroke |
| AVOID hydralazine | AVOID | N/A | N/A | Unpredictable BP drop magnitude + delayed onset → risk of overshoot through penumbral perfusion floor; AHA/ASA 2024 not recommended in acute stroke |
Plan: HTN in acute ischemic stroke — reperfusion-band-specific BP target (lytic <185/110 pre-bolus, <180/105 × 24 h post; thrombectomy 140-180 pre-procedure; permissive >220/120 if not eligible)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: AHA/ASA 2024 Acute Ischemic Stroke Guideline (Greenberg PMID 38483443) + 2025 ACC/AHA HTN Guideline (Whelton) + ESC/ESH 2024 HTN (Mancia PMID 38613493)