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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e165 5.3.9.1 Acute Intracerebral Hemorrhage Recommendations for Acute Intracerebral Hemorrhage COR LOE Recommendations 2a A 1 For adult patients with acute spontaneous intra cerebral hemorrhage (ICH) who present with SBP between 150 and 220 mm Hg, it can be beneficial to immediately lower SBP to 130 to <140 mm Hg for at least 7 days after ICH to improve functional outcomes but stop antihypertensive medications if SBP <130 mm Hg.1–3 2a B-NR 2 In adults with acute spontaneous ICH requir ing acute BP lowering, careful titration to ensure smooth, nonlabile, and sustained control of BP, avoiding peaks and large variability in SBP, can be beneficial for improving functional outcomes.3,4 3: Harm B-NR 3 For adult patients with acute spontaneous ICH who present with SBP >220 mm Hg, SBP should not be lowered below 130 mm Hg to reduce adverse events.5–7 Synopsis Spontaneous, nontraumatic ICH is a significant global cause of morbidity and mortality.8 Elevated BP is highly prevalent in the setting of acute ICH and is linked to greater hematoma expansion, neurological worsening, and death and dependency after ICH.1–3,9 Recommendation-Specific Supportive Text 1 INTERACT-2 (The Second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) showed improvement in secondary outcomes of overall func tion and quality of life with lowering SBP to <140 mm Hg and maintaining for 7 days for noncomatose spon taneous ICH patients who presented with an SBP of 150 to 220 mm Hg within 6 hours of onset of ICH.2 INTERACT 3 (Third Intensive Care Bundle With Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) concluded that an early intensive SBP lowering of <140 mm Hg (bundled with strict blood glucose control, antipyrexia treatment, and rapid reversal of warfarin treatment within 1 hour) and maintenance for 7 days was associated with overall improved long-term functional outcome compared with usual care.3 Both trials protocolized stopping antihypertensive medica tions if SBP lowered <130 mm Hg. A meta-analysis of INTERACT-2 and ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage II) trial showed an improved 90-day global disability with incrementally lower achieved SBP up to 130 mm Hg.3 In a post-hoc analysis of the INTERACT-2 trial, SBP <130 mm Hg was harmful.6 2 A post hoc analysis of INTERACT-2 found that increased standard deviation of SBP during the first 24 hours had a linear association with death and severe disability at 90 days.4 A meta-analysis of INTERACT-2 and ATACH-2 also showed a con tinuous association between achieved SBP and lesser variability during the first 24 hours after ICH and the distribution of modified Rankin scale scores at 90 days, suggesting that avoiding large fluctuations in BP is beneficial.3 There is a lack of evidence to guide the choice of BP-lowering agents during the hyperacute phase after ICH, including bolus versus drip management. IV nica rdipine was the drug used in ATACH-2, whereas a range of IV and oral BP-lowering agents were used in INTERACT-2 and INTERACT 3. Any antihyper tensive drug with rapid onset and short duration of action to facilitate easy titration and sustained BP control to minimize SBP variability seems appropri ate, although venous vasodilators may be harmful because of unopposed venodilation and its effect on hemostasis and intracranial pressure.10 In a meta-analysis of 50 studies, use of a titratable agent and CCB and alpha- and beta-adrenoceptor blockers were associated with favorable outcomes compared with other fixed agent use and RAS blockers, nitrates, and magnesium.3 3 A post-hoc analysis of the ATACH-2 trial showed that among 228 participants with ICH of mild-to-moderate severity who had SBP >220 mm Hg at presentation, intensive lowering of their SBP where the achieved values were <130 mm Hg was harmful.7 However, given the consistent nature of the data linking high BP with poor clinical outcomes and data favoring modest SBP lowering in patients with moderately high initial SBP levels,1–3 cautious, modest lowering of SBP (in the range of 160-180 mm Hg) in ICH patients with markedly high SBP levels (>220 mm Hg) might be reasonable. 5.3.9.2 Acute Ischemic Stroke Recommendations for Acute Ischemic Stroke References that support recommendations are summarized in the Evidence Table. COR LOE Recommendations 1 C-LD 1 In patients with acute ischemic stroke, hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to support organ function.1–3 1 B-NR 2 Patients who have elevated BP and are otherwise eligible for treatment with IV thrombolytics should have their BP lowered to SBP <185 mm Hg and DBP <110 mm Hg before IV thrombolytic therapy is initiated and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating thrombolytic therapy to avoid complications.4,5 2a B-NR 3. In patients who undergo endovascular treatment, it is reasonable to maintain the BP at ≤180/105 mm Hg during and for 24 hours after the procedure to improve long-term functional outcomes and prevent death.6,7 2b C-LD 4 In patients with BP of ≥220/120 mm Hg who did not receive IV thrombolytic or endovascular treatment and have no comorbid conditions requiring acute antihypertensive treatment, it might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke to improve outcomes.2,3 Downloaded from http://ahajournals.org by on October 7, 2026