Table 12.4-2. Treatment of hypertension in patients with recent ischemic stroke who are eligible for fibrinolytic treatment (examples; other medications are possible)

Before fibrinolytic treatment

Do not administer rtPA if BP cannot be maintained ≤185/110 mm Hg

Patient eligible for rtPA administration except for SBP >185 mm Hg and/or DBP >110 mm Hg

– IV labetalol 10-20 mg over 1-2 min, may be repeated once


– IV nicardipine 5 mg/h, titrate up by 2.5 mg/h every 5-15 min (max rate, 15 mg/h). When target BP is achieved, adjust to maintain appropriate BP range


– IV clevidipine 1-2 mg titrated by doubling the dose every 2-5 min until target is reached (max, 21 mg/h)


– Other agents (eg, hydralazine, enalaprilat) may be considered

During or after fibrinolytic treatment

– Maintain BP ≤180/105 mm Hg (use IV labetalol 10 mg followed by infusion 2-8 mg/h, nicardipine (max, 15 mg/h), or clevidipine (max, 21 mg/h)

– Monitor BP every 15 min for 2 h following the start of rtPA administration, then every 30 min for 6 h, and then every hour for 16 h

BP cannot be controlled with labetalol or nicardipine or DBP >140 mm Hg

– Admission to ICU

– IV sodium nitroprusside 0.5 microg/kg/min

BP, blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; rtPA, recombinant tissue plasminogen activator; SBP, systolic blood pressure.