Acute stroke hypertension: current and future management

The management of hypertension in acute stroke remains a hotly debated issue. Clinical practice varies widely between physicians, and both European and US guidelines reflect the uncertainty surrounding this question. Although there is a large amount of data that, on the whole, tends to support a connection between poststroke hypertension and hypotension and worse outcome, there have been few randomized controlled trials to clarify whether pharmacologic intervention is safe or beneficial. Data from secondary prevention trials convincingly demonstrate the benefits of controlling hypertension after a stroke but do not guide us as to how early to implement therapy. There is even less information from trials regarding the use of pressor agents in hypotensive stroke patients. This review discusses the dilemmas in the management of acute stroke hypertension and summarizes the available evidence from studies involving a variety of both depressor and pressor agents. The authors detail the ongoing studies that will help to answer some of the outstanding questions and summarizes the existing guidelines regarding indications for acute stroke blood pressure manipulation currently available to physicians.