There is also no robust evidence to suggest which first-line antihypertensive drug class provides more benefit than harm in hypertensive emergencies. For most hypertensive emergencies, IV administration of a short half-life drug under continuous haemodynamic monitoring is recommended to allow careful titration of the response to treatment.

Esmolol, metoprolol, labetalol, fenoldopam, clevidipine, nicardipine, nitroglycerine, nitroprusside, enalaprilat, urapidil, clonidine and phentolamine are all recommended. In general, use of oral therapy is discouraged.

The survival of patients with hypertensive emergencies has improved dramatically over the past decades. However, these patients still have a high mortality risk and should be screened for secondary hypertension. Careful long-term follow up is also of utmost importance.

Blood Pressure Management in Hypertensive Emergencies Involving Brain Damage. BP management in hypertensive emergencies involving brain damage hypertensive encephalopathy, intracerebral hemorrhage and acute ischaemic stroke should consider that the pathophysiology of brain damage is unique to each condition.

Consequently, the right diagnosis is crucial based upon clinical features, brain imaging, neurovascular evaluations and cardiac tests. The diagnosis of hypertensive encephalopathy is based on the presence of vague neurologic symptoms, headache, confusion, visual disturbances, seizures, nausea and vomiting.

The onset of symptoms usually occurs over 24—48 hours with neurological progression. The examination can show retinopathy haemorrhages, exudates and papilledema , transient and migratory neurological nonfocal deficits ranging from nystagmus to weakness and an altered mental state ranging from confusion to coma.

Focal neurological lesions are rare and should raise the suspicion of stroke. Symptoms are usually reversible with prompt initiation of therapy. Agents that affect the central nervous system, such as clonidine, reserpine and methyldopa, and diuretics should be avoided.

Posterior reversible encephalopathy syndrome PRES has been increasingly recognised as a complication of hypertensive encephalopathy. Hypertension with failed autoregulation, dysfunction of the blood brain barrier, arteriolar dilatation and hyperperfusion leading to vasogenic oedema have all been implicated in its pathophysiology.

The clinical presentation can be very similar to a hypertensive encephalopathy including headache, nausea, hemiparesis, hemianopsia, seizures and coma. Findings from brain MRI are typical and show symmetric hyperintensities in the subcortical white matter of the posterior temporal and occipital lobes in the fluid-attenuated inversion recovery sequences.

Some patients can also present with string-of-beads and focal vasodilatation-vasoconstriction areas in the cerebral angiogram, a finding compatible with reversible cerebral vasoconstriction syndrome. However, PRES can also occur in patients without elevated BP levels, including those using immunosuppressive drugs, after organ and bone marrow transplantation and in patients with sepsis and multiorgan failure.

Acute ischaemic strokes occur due to an occlusion of an intracranial or cervical artery with consequent deprivation of blood and oxygen to a brain territory. A few minutes after an arterial occlusion in the brain, a core ischaemic lesion is established, however a larger area at risk of hypoperfusion can be salvageable if recanalisation therapies are administered.

The salvageable area or ischaemic penumbra is largely dependent on collateral blood flow and acute reductions of BP can threaten perfusion in critical areas. In the acute phase of ischaemic stroke, early initiation or resumption of antihypertensive treatment is indicated only in patients treated with recombinant tissue-type plasminogen activator or if hypertension is extreme.

The benefit of acute BP lowering in patients with acute ischaemic stroke who do not receive thrombolysis is uncertain. Rapid reduction of BP, even to lower levels in the hypertensive range, can be detrimental. Restarting BP control is reasonable after the first 24 hours for hypertensive patients who are stable.

Spontaneous, non-traumatic intracerebral haemorrhage is the second most common cause of stroke after ischaemic stroke. The most common causes are hypertension, bleeding diatheses, amyloid angiopathy, drug misuse and vascular malformations.

Subarachnoid haemorrhage is another subtype of haemorrhagic stroke. The two major causes of subarachnoid haemorrhage are rupture of arterial aneurysms that lie at the base of the brain and bleeding from vascular malformations that lie near the pial surface.

In patients with intracerebral haemorrhage, BP is often elevated and hypertension is linked to greater haematoma expansion, neurological deterioration and worse prognosis.

However, the management of hypertension is complicated by competing risks reducing cerebral perfusion pressure in patients with intracranial hypotension and potential benefits reducing further bleeding. A favourable trend was also seen toward a reduction in the conventional clinical end point of death and major disability.

Intracranial pressure is another important parameter to be considered in patients with intracerebral haemorrhage. If the systolic BP is higher than mmHg and there is evidence or suspicion of elevated intracranial pressure, it is recommended to keep cerebral perfusion pressure at 61—80 mmHg.

If the systolic BP is — mmHg, acute lowering to mmHg is probably safe. The management of BP in the acute phase of subarachnoid haemorrhage is based on even less clinical evidence.

Observational studies suggest that aggressive treatment of BP may reduce the risk of aneurysmal rebleeding, but with an increased risk of secondary ischaemia. Guidelines from different clinical societies agree that is reasonable to treat BP if the aneurysm is not yet secured, although the levels recommended in the guidelines differ.

The risk is also high after a transient ischaemic attack TIA or a minor ischaemic stroke. Data from a registry of TIA clinics in 21 countries that enrolled 4, patients showed that at 1-year follow-up, the rate of cardiovascular events including stroke was 6. There are gaps in the evidence for the management of BP for secondary prevention of stroke and there is a need for further studies.

BP-lowering therapy should be considered in patients with stable neurological status, 72 hours after onset of neurologic symptoms, or immediately after TIA, for previously treated or untreated patients with hypertension, except in patient with large vessel occlusion and fluctuating clinical symptoms.

A Cochrane review of randomised controlled trials investigating BP-lowering treatment for the prevention of recurrent stroke, major vascular events and dementia in patients with a history of stroke or TIA.

The BP-lowering drugs started at least 48 hours after stroke or TIA. The authors concluded that the results support the use of BP-lowering drugs in people with stroke or TIA for reducing the risk of recurrent stroke and that the current evidence is primarily derived from trials studying an ACE inhibitor or a diuretic and that no definite conclusions can be drawn from current evidence regarding an optimal systolic BP target after stroke or TIA.

Reducing BP appears to be more important than the choice of agents and the effectiveness of the BP reduction diminishes as initial baseline BP declines.

Angiotensin inhibitors, calcium channel blockers and diuretics are reasonable options for initial antihypertensive monotherapy and may be used in such patients. Beta-blockers should not be given unless there is a compelling indication for their use, particularly as the most common recurrent event after stroke is a further stroke rather than MI.

Projections show that by , an additional 3. Evidence of the benefits are weaker for lower BP targets obtained with intensive BP lowering, especially in older patients. The management of BP in adults with stroke is complex and challenging because of its heterogeneous causes and haemodynamic consequences.

Future studies should focus on optimal timing and targets for BP reduction, as well as ideal antihypertensive agent therapeutic class by patient type and event type.

New strategies to identify and reduce stroke risk and improve management of acute stroke are necessary. Markers for increased risk may improve prevention. Achieving control of behavioural and metabolic risk factors could avert more than three-quarters of the global stroke burden.

Health promotion strategies for positive cardiovascular health should be emphasised, in addition to the treatment of established CVD. Unfortunately, the number of people — even young people — who have far from ideal cardiovascular health is still high.

Healthcare providers should have tools for quality improvement interventions on adherence to evidence-based therapies. Primordial prevention strategies that prevent the emergence of stroke risk factors should be the ultimate goal. Measures such as salt reduction and dietary interventions, implementation of tobacco control and support to the development of healthy environment are crucial for reducing the burden of cardiovascular diseases.

This endeavour needs close collaboration between healthcare professionals, institutions and governments. ICR 3. ECR is the official journal of the.

About ECR. Editorial Board. For Authors. Special Collections. Submit Article. Mauricio Wajngarten ,. Gisele Sampaio Silva ,. Register or Login to View PDF Permissions Permissions × For commercial reprint enquiries please contact Springer Healthcare: ReprintsWarehouse springernature.

For permissions and non-commercial reprint enquiries, please visit Copyright. com to start a request. For author reprints, please email rob. barclay radcliffe-group. Average ratings No ratings. Your rating Sign in to rate.

Abstract Stroke is the second most common cause of mortality worldwide and the third most common cause of disability. Keywords Hypertension , stroke , treatment , prevention , emergency , public health ,. Citation ×. Select format. Breadcrumb Home What is a stroke? Are you at risk of stroke?

The information on this page can be accessed in the following formats: Download this information as a pdf or large print document.

Order a printed copy from our shop To request a braille copy, email helpline stroke. uk On this page: Staying healthy and reducing high blood pressure What is high blood pressure? What is high blood pressure? Strokes due to a clot ischaemic stroke High blood pressure damages your blood vessels by making them become narrower and stiffer, and causing a build-up of fatty material.

Stroke and cognitive problems due to small vessel disease Small vessel diseases means having damage to the tiny blood vessels deep inside the brain. Stroke due to bleeding in or around the brain haemorrhagic stroke High blood pressure can damage blood vessels inside the brain, causing bleeding in the brain.

Tailoring your treatment There are several different types of medication for high blood pressure, and we know that age, ethnicity and family history affect how they work. Getting started with your medication It can sometimes take a while to adjust to taking a long-term medication.

Pharmacy-based support service England only In England, you can join the New Medicines Service NMS by asking your local pharmacist. How long will I be on medication? Side effects and drug interactions Like all medications, blood pressure medications can cause side effects.

Lifestyle changes quick guide On top of medication, healthy lifestyle changes can often help to lower your blood pressure even more. Reduce your salt intake. Have a look at our guide to healthy eating after stroke for some ideas on how to do this.

Get help with quitting smoking. Eat plenty of fruit and vegetables. Lose weight if you need to. Reduce your alcohol intake and avoid binge drinking. Be more active. Reduce your stress levels and take time to relax. Try to get at least six hours sleep a night.

How is high blood pressure diagnosed? How is blood pressure measured? Understanding your blood pressure reading Your blood pressure reading is recorded as two numbers. Systolic: the pressure when your heart beats. Diastolic: the pressure in between heartbeats.

What do the numbers mean? Why is the target level lower for home blood pressure testing? Monitoring your blood pressure How often should I get checked? If you have been diagnosed with high blood pressure, you should be monitored until you reach your target blood pressure.

Afterwards you should have an annual check. All adults should have their blood pressure checked at least every five years.

Who can get high blood pressure? Some things that put you at greater risk of high blood pressure include: Eating too much salt. Being inactive. Being overweight. Drinking more than the safe limits for alcohol. Some health conditions can cause high blood pressure, including: Kidney disease.

Obstructive sleep apnoea interrupted breathing during sleep. Lupus immune disorder. High blood pressure in pregnancy If you have high blood pressure during pregnancy, your blood pressure will be monitored during pregnancy, labour and after the birth.

Quick guide to blood pressure medication This guide can only give general information. The main groups of blood pressure medication are: ACE inhibitors. Abbreviated from angiotensin-converting enzyme. Angiotensin-2 receptor blockers ARB. Calcium channel blockers. Thiazide-like diuretics.

Other types of medication. ACE inhibitors ACE inhibitors work by relaxing your blood vessels. How to take it They are usually taken as a tablet once a day. Common side effects The most common side effect is a persistent dry cough. Angiotensin-2 receptor blockers ARB Like ACE inhibitors, these work on the hormone angiotensin-2 by blocking its effects.

They can help to protect your kidneys if you have diabetes or kidney disease. Try to take it at the same time every day. Common side effects Possible side effects are usually mild and include dizziness, headache or nausea.

Calcium channel blockers They stop calcium from entering the muscle cells in your heart and blood vessels. Common side effects Possible side effects include swollen ankles, ankle or foot pain, constipation, skin rashes, a flushed face, headaches, dizziness and tiredness.

Thiazide-like diuretics Examples include indapamide, bendroflumethiazide, chlortalidone and cyclopenthiazide. Common side effects Possible side effects include needing to wee more often, thirst, dizziness, weakness, feeling lethargic or sick, muscle cramps and skin rash. Other types of medication Beta-blockers Beta-blockers work by making your heart beat more slowly and with less force, which reduces your blood pressure.

Examples of beta-blockers include labetalol, atenolol, and bisoprolol. Other medication groups Other medications that may be used to control blood pressure include doxazosin and terazosin which belong to a group called alpha-blockers , and clonidine and methyldopa which belong to a group called centrally acting drugs.

Bibliography 1. Tags: Blood pressure Hypertension Preventing stroke Prevention Risk-factors. Book: Are you at risk of stroke?

Related pages. Exercising after stroke. Useful links. NHS high blood pressure information. Close Home Need help? Call us Stroke Helpline Supporter Relations About stroke Types of stroke What is a TIA mini stroke? What are the symptoms of stroke? What causes stroke? Childhood stroke What happens when you have a stroke?

What are the effects of stroke? Aphasia and communication Serious illness and end of life Support for you Stroke Helpline Local services Stroke support groups Join our online forum Life after stroke Financial help after a stroke Caring for a stroke survivor Resources for professionals Childhood stroke support service Guides and factsheets Read Stroke News magazine Fundraising and giving Donating and paying in fundraising money Find an event or challenge Virtual events Organise an event Remembering someone special Give in celebration Leave a gift in your will Philanthropy Corporate partnerships Explore ways to fundraise Play our lottery and raffle Supporter relations Get involved Volunteer with us Campaigning Conferences and events Help shape our work Shape stroke research Apply for research funding Job opportunities About us Contact us Who we are Research Our work with health professionals Our partnerships Accountability and policies Latest news Media newsroom Forum Shop Donate.

High Blood Pressure and Stroke Fact Sheet pdf. How to check that a blood pressure monitor has been properly tested for accuracy. Where am I? Home About Stroke Prevent Stroke High blood pressure.

High blood pressure High blood pressure, also known as hypertension , is the most important known risk factor for stroke.

High blood pressure can lead to a stroke in several ways: It damages blood vessel walls and makes them weaker. It can speed up common forms of heart disease.

It can cause blood clots or plaques to break off artery walls and block a brain artery.