European Stroke Organisation (ESO) guidelines on blood pressure management in acute ischaemic stroke and intracerebral haemorrhage

Abstract

The optimal blood pressure (BP) management in acute ischaemic stroke (AIS) and acute intracerebral haemorrhage (ICH) remains controversial. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist physicians in their clinical decisions regarding BP management in acute stroke. The guidelines were developed according to the ESO standard operating procedure and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. Despite several large randomised-controlled clinical trials, quality of evidence is generally low due to inconsistent results of the effect of blood pressure lowering in AIS. We recommend early and modest blood pressure control (avoiding blood pressure levels >180/105 mm Hg) in AIS patients undergoing reperfusion therapies. There is more high-quality randomised evidence for BP lowering in acute ICH, where intensive blood pressure lowering is recommended rapidly after hospital presentation with the intent to improve recovery by reducing haematoma expansion. These guidelines provide further recommendations on blood pressure thresholds and for specific patient subgroups. There is ongoing uncertainty regarding the most appropriate blood pressure management in AIS and ICH. Future randomised-controlled clinical trials are needed to inform decision making on thresholds, timing and strategy of blood pressure lowering in different acute stroke patient subgroups.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management

“…33 Large haematoma volumes and haematoma expansion are associated with poor clinical outcome 34 leading to a recommendation for early BP management. 35 Furthermore, given the fact that the use of anticoagulation has been associated with haemorrhage growth, anticoagulation reversal represents a key treatment option for ICH patients on anticoagulation therapy. 36…”

Cerebrovascular Disease and Hypertension

“…Practical strategies for management of hypertension in AIS, based on recommendations of AHA/ASA [36], and European stroke organization (ESO) [37] include:…”

“…Drugs for acute management of elevated blood pressures in patients of acute ischemic stroke who are planned for emergency reperfusion therapy [36,37].…”

“…Practical strategies for BP control in patients with acute hemorrhagic stroke based on recent AHA/ASA [50], and ESO [37] guidelines include:…”

“…2. In patients with initial systolic BP of 150-220 mm Hg, American guidelines suggest a target goal of 140-150 mm Hg of systolic BP [50], however, the recent ESO guidelines [37] recommend even more aggressive lowering of systolic BP to less than 140 mm Hg (but to keep it above 110 mm Hg) to reduce hepatoma expansion.…”