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CLINICAL STATEMENTS AND GUIDELINES September 16, 2025 Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 e166 3: No Benefit A 5 In patients with BP <220/120 mm Hg who do not receive IV thrombolysis or endovascular treatment and do not have a comorbid condition requiring urgent antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or disability.8–11 3: Harm A 6 In patients undergoing successful brain reperfu sion with endovascular treatment for a large vessel occlusion, lowering SBP <140 mm Hg within the first 24 to 72 hours after reperfusion can worsen long-term functional outcome.12–14 Synopsis High BP occurs in up to 80% of acute stroke patients.15 Counteracting concerns about hypertension during acute ischemic stroke include enhancing cerebral per fusion while minimizing brain edema and hemorrhagic transformation of the ischemic tissue.2,16 Some studies have shown a U-shaped relationship between the ad mission BP and favorable clinical outcomes.3 Cerebral autoregulation in the ischemic penumbra of the stroke is grossly abnormal, and adequate systemic perfusion pressure is needed for blood flow and oxygen delivery. Rapid reduction of BP, even to levels within the hyper tensive range, can be detrimental. Treatment of hyper tension in acute ischemic stroke is dependent on the following conditions: 1) treatment with IV thromboly sis, 2) treatment with endovascular thrombectomy with successful reperfusion, 3) patients with SBP >220 mm Hg or DBP >120 mm Hg, and 4) comorbid conditions requiring treatment. For all other acute ischemic stroke patients, the advantage of lowering BP early to reduce death and dependency is uncertain.8,9,17,18 It should be noted that early treatment of hypertension is indicated when required by comorbid conditions (eg, concomi tant acute coronary event, acute HF, aortic dissection, postfibrinolysis symptomatic ICH, or preeclampsia/ec lampsia). Recommendation-Specific Supportive Text 1 The BP level that should be maintained in patients with acute ischemic stroke to ensure the best out come is unknown. Observational studies conflict with an association between worse outcomes and lower BP.1–3,19 No studies have addressed the treatment of low BP in patients with stroke. In a systematic analy sis of 12 studies comparing the use of IV colloids and crystalloids, the odds of death or dependence were similar. Clinically important benefits or harms could not be excluded. There are no data to guide volume and duration of parenteral fluid delivery.20 No studies have compared different isotonic fluids. 2. The RCTs of IV alteplase required the SBP to be <185 mm Hg and DBP <110 mm Hg before treatment and SBP <180 mm Hg and DBP <105 mm Hg for the first 24 hours after treatment.4,5 Observational studies and meta-analyses sug gest that the risk of hemorrhage after administra tion of alteplase is greater in patients with higher BPs and in patients with more BP variability.21,22 The exact BP at which the risk of hemorrhage after IV alteplase increases is unknown. It is thus reasonable to target the BPs used in the RCTs of IV alteplase. ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) showed that antihypertensive treatment to target SBP 130 to 140 mm Hg within 6 hours of stroke onset in patients treated with IV thrombolytic did not show improvement in outcome.9 3 Data from large observational studies and meta- analyses suggest that higher BP after endovas cular thrombectomy, particularly for those who undergo successful reperfusion, is associated with worse functional outcomes.6,7,23 The majority of the RCTs of endovascular thrombectomy for acute ischemic stroke protocolized an SBP target of <180 mm Hg after treatment. No RCT has stud ied a post-endovascular thrombectomy SBP target higher than 180 mm Hg. 4. Patients with severe hypertension (most commonly SBP/DBP >220/>120 mm Hg) were excluded from clinical trials evaluating BP lowering after acute ischemic stroke.8–11 Rapid BP reduction has traditionally been advised for these cases, but the benefit of such treatment in the absence of comor bid conditions that may be acutely exacerbated by severe hypertension has not been formally studied, and the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. Ideal management in these situations should be individualized, with an initial BP reduc tion of 15% a reasonable goal. Excessive drop in BP could result in complications, such as stroke progression, by compromising cerebral perfusion in penumbral tissue and AKI from renal hypoperfu sion. There are no data to show that one strategy to lower BP is better than another after acute isch emic stroke. 5. Multiple RCTs and meta-analyses of these trials have consistently shown that initiating or reinitiat ing antihypertensive therapy within the first 48 to 72 hours after an acute ischemic stroke is safe, but this strategy is not associated with improved mortality or functional outcomes.8,10,11,17,18 However, none of these trials included patients with extreme hypertension or coexistent indications for rapid BP reduction. 6. RCTs and meta-analysis of RCTs evaluating BP low ering after successful endovascular thrombectomy to date have shown either harm or no benefit.12–14,24 Recommendations for Acute Ischemic Stroke (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026