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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;152:e114–e218. DOI: 10.1161/CIR.0000000000001356 September 16, 2025 e203

6 Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering

in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375:1033– 1043. 7.	 Qureshi AI, Huang W, Lobanova I, et al. Outcomes of intensive systolic blood pressure reduction in patients with intracerebral hemorrhage and exces­ sively high initial systolic blood pressure: post hoc analysis of a randomized clinical trial. JAMA Neurol. 2020;77:1355–1365. 8.	 Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke statistics: a report of US and global data from the American Heart Associa­ tion. Circulation. 2024;149:e347-e913. 9.	 Boulouis G, Morotti A, Goldstein JN, et al. Intensive blood pressure low­ ering in patients with acute intracerebral haemorrhage: clinical outcomes and haemorrhage expansion. Systematic review and meta-analysis of ran­ domised trials. J Neurol Neurosurg Psychiatry. 2017;88:339–345. 10.	 Bath PM, Woodhouse LJ, Krishnan K, et al. Prehospital transdermal glyceryl

trinitrate for ultra-acute intracerebral hemorrhage: data from the RIGHT-2 trial. Stroke. 2019;50:3064–3071.

5.3.9.2 Acute Ischemic Stroke

1 Wohlfahrt P, Krajcoviechova A, Jozifova M, et al. Low blood pressure during

the acute period of ischemic stroke is associated with decreased survival. J Hypertens. 2015;33:339–345. 2.	 Leonardi-Bee J, Bath PM, Phillips SJ, et al. Blood pressure and clinical out­ comes in the International Stroke Trial. Stroke. 2002;33:1315–1320. 3.	 Vemmos KN, Tsivgoulis G, Spengos K, et al. U-shaped relationship between mortality and admission blood pressure in patients with acute stroke. J In­ tern Med. 2004;255:257–265. 4.	 National Institute of Neurological Disorders Stroke, PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–1587. 5.	 Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317– 1329. 6.	 Katsanos AH, Malhotra K, Ahmed N, et al. Blood pressure after endovascu­ lar thrombectomy and outcomes in patients with acute ischemic stroke: an individual patient data meta-analysis. Neurology. 2022;98:e291-e301. 7.	 Anadani M, Arthur AS, Alawieh A, et al. Blood pressure reduction and out­ come after endovascular therapy with successful reperfusion: a multicenter study. J Neurointerv Surg. 2020;12:932–936. 8.	 Liu L, Xie X, Pan Y, et al. Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial. BMJ. 2023;383:e076448. 9.	 Anderson CS, Huang Y, Lindley RI, et al. Intensive blood pressure reduc­ tion with intravenous thrombolysis therapy for acute ischaemic stroke (EN­ CHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial. Lancet. 2019;393:877–888. 10.	 He J, Zhang Y, Xu T, et al. Effects of immediate blood pressure reduction on death and major disability in patients with acute ischemic stroke: the CATIS randomized clinical trial. JAMA. 2014;311:479–489. 11.	 Sandset EC, Bath PM, Boysen G, et al. The angiotensin-receptor blocker candesartan for treatment of acute stroke (SCAST): a randomised, placebocontrolled, double-blind trial. Lancet. 2011;377:741–750. 12.	 Yang P, Song L, Zhang Y, et al. Intensive blood pressure control after endo­ vascular thrombectomy for acute ischaemic stroke (ENCHANTED2/MT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lan­ cet. 2022;400:1585–1596. 13.	 Nam HS, Kim YD, Heo J, et al. Intensive vs conventional blood pressure lowering after endovascular thrombectomy in acute ischemic stroke: the OPTIMAL-BP randomized clinical trial. JAMA. 2023;330:832–842. 14.	 Mistry EA, Hart KW, Davis LT, et al. Blood pressure management after endo­ vascular therapy for acute ischemic stroke: the BEST-II randomized clinical trial. JAMA. 2023;330:821–831. 15.	 Qureshi AI, Ezzeddine MA, Nasar A, et al. Prevalence of elevated blood pressure in 563 704 adult patients with stroke presenting to the ED in the United States. Am J Emerg Med. 2007;25:32–38. 16.	 Castillo J, Leira R, Garcia MM, et al. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004;35:520–526. 17.	 Enos Trial Investigators. Efficacy of nitric oxide, with or without continu­ ing antihypertensive treatment, for management of high blood pressure in acute stroke (ENOS): a partial-factorial randomised controlled trial. Lancet. 2015;385:617–628. 18.	 Zhao R, Liu FD, Wang S, et al. Blood pressure reduction in the acute phase

of an ischemic stroke does not improve short- or long-term dependency or mortality: a meta-analysis of current literature. Medicine (Baltimore). 2015;94:e896. 19.	 Muscari A, Puddu GM, Serafini C, et al. Predictors of short-term improve­

ment of ischemic stroke. Neurol Res. 2013;35:594–601. 20.	 Visvanathan A, Dennis M, Whiteley W. Parenteral fluid regimens for improv­ ing functional outcome in people with acute stroke. Cochrane Database Syst Rev 2015;2015:CD011138. 21.	 Waltimo T, Haapaniemi E, Surakka IL, et al. Post-thrombolytic blood pressure and symptomatic intracerebral hemorrhage. Eur J Neurol. 2016;23:1757– 1762. 22.	 Malhotra K, Ahmed N, Filippatou A, et al. Association of elevated blood pres­ sure levels with outcomes in acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis. J Stroke. 2019;21:78–90. 23.	 Mistry EA, Sucharew H, Mistry AM, et al. Blood pressure after endovascular therapy for ischemic stroke (BEST): a multicenter prospective cohort study. Stroke. 2019;50:3449–3455. 24.	 Ghozy S, Mortezaei A, Elfil M, et al. Intensive vs conventional blood pressure

control after thrombectomy in acute ischemic stroke: a systematic review and meta-analysis. JAMA Netw Open. 2024;7:e240179.

5.3.9.3 Secondary Stroke Prevention

1 Zonneveld TP, Richard E, Vergouwen MD, et al. Blood pressure-lowering

treatment for preventing recurrent stroke, major vascular events, and de­ mentia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev 2018;7:CD007858. 2.	 Wang WT, You LK, Chiang CE, et al. Comparative effectiveness of blood pressure-lowering drugs in patients who have already suffered from stroke: traditional and Bayesian network meta-analysis of randomized trials. Medi­ cine (Baltimore). 2016;95:e3302. 3.	 Katsanos AH, Filippatou A, Manios E, et al. Blood pressure reduction and secondary stroke prevention: a systematic review and metaregression anal­ ysis of randomized clinical trials. Hypertension. 2017;69:171–179. 4.	 Progress Collaborative Group. Randomised trial of a perindoprilbased blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033– 1041. 5.	 Kitagawa K, Yamamoto Y, Arima H, et al. Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: a randomized clinical trial and meta-analysis. JAMA Neurol. 2019;76:1309–1318. 6.	 Mant J, McManus RJ, Roalfe A, et al. Different systolic blood pressure tar­ gets for people with history of stroke or transient ischaemic attack: PAST- BP (Prevention After Stroke--Blood Pressure) randomised controlled trial. BMJ. 2016;352:i708. 7.	 Bath PM, Scutt P, Blackburn DJ, et al. Intensive versus guideline blood pres­ sure and lipid lowering in patients with previous stroke: main results from the pilot 'Prevention of Decline in Cognition after Stroke Trial' (PODCAST) randomised controlled trial. PLoS One. 2017;12:e0164608. 8.	 Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke statistics: a report of US and global data from the American Heart Associa­ tion. Circulation. 2024;149:e347-e913. 9.	 Lin Q, Ye T, Ye P, et al. Hypertension in stroke survivors and associations with national premature stroke mortality: data for 2.5 million participants from multinational screening campaigns. Lancet Glob Health. 2022;10:e1141e1149. 10.	 Zheng S, Yao B. Impact of risk factors for recurrence after the first ischemic stroke in adults: a systematic review and meta-analysis. J Clin Neurosci. 2019;60:24–30. 11.	 Biffi A, Anderson CD, Battey TW, et al. Association between blood pres­ sure control and risk of recurrent intracerebral hemorrhage. JAMA. 2015;314:904–912. 12.	 Nguyen-Huynh MN, Hills NK, Sidney S, et al. Race-ethnicity on blood pres­ sure control after ischemic stroke: a prospective cohort study. J Am Soc Hypertens. 2017;11:38–44. 13.	 Zahuranec DB, Wing JJ, Edwards DF, et al. Poor long-term blood pressure control after intracerebral hemorrhage. Stroke. 2012;43:2580–2585. 14.	 Rodriguez-Torres A, Murphy M, Kourkoulis C, et al. Hypertension and intra­ cerebral hemorrhage recurrence among White, Black, and Hispanic indi­ viduals. Neurology. 2018;91:e37-e44. 15.	 Liu L, Wang Z, Gong L, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the litera­ ture. Hypertens Res. 2009;32:1032–1040. 16.	 Schrader J, Luders S, Kulschewski A, et al. Morbidity and mortality after stroke,

eprosartan compared with nitrendipine for secondary prevention: principal

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