Table 7. Emergency Antihypertensive Therapy for Acute Ischemic Stroke
Blood Pressure* Treatment
Nonthrombolytic candidates
1. DBP > 140 mm Hg Sodium nitroprusside (0.5 µg/kg per minute). Aim for 10% to 20% reduction in DBP.
2. SBP> 220, or DBP 121 to 140, or MAP† > 130 mm Hg 10 to 20 mg labetalol‡ IV push over 1 to 2 minutes. May repeat or double labetalol every 20 minutes to a maximum dose of 150 mg.
3. SBP < 220, DBP 120, or MAP† > 130 mm Hg Emergency antihypertensive therapy is deferred in the absence of aortic dissection, acute myocardial infarction, severe congestive heart failure, or hypertensive encephalopathy.
Thrombolytic candidates

Pretreatment
1. SBP > 185 or DBP > 110 mm Hg 1 to 2 inches of nitropaste or 1 to 2 doses of 10 to 20 mg labetalol‡ IV push. If BP is not reduced and maintained to < 185/110 mm Hg, the patient should not be treated with TPA

During and after treatment
1. Monitor BP BP is monitored every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then every 1 hour for 16 hours.
2. DBP > 140 mm Hg Sodium nitroprusside (0.5 µg/kg per minute).
3. SBP > 230 or DBP 121 to 140 mm Hg

 (1) 10 mg labetalol‡ IVP over 1 to 2 minutes. May repeat or double labetalol every 10 minutes to a maximum dose of 150 mg or give the initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min.

(2) If BP not controlled by labetalol, consider sodium nitroprusside.

4. SBP 180 to 230 or DBP 105 to 120 mm Hg 10 mg labetalol‡ IVP. May repeat or double labetalol every 10 to 20 minutes to a maximum dose of 150 mg or give initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min.
DBP indicates diastolic blood pressure; SBP, systolic blood pressure; MAP, mean arterial pressure;
BP, blood pressure; and TPA, tissue plasminogen activator.
*All initial blood pressures should be verified before treatment by repeating reading in 5 minutes.
†As estimated by one third the sum of systolic and double diastolic pressure.
‡Labetalol should be avoided in patients with asthma, cardiac failure, or severe abnormalities in cardiac conduction. For refractory hypertension, alternative therapy may be considered with sodium nitroprusside or enalapril.