Telah dilaporkan data berskala besar di Amerika Serikat bahwa umumnya Tekanan

Darah Sistolik pasien stroke yang datang di unit gawat darurat berkisar antara 140-184mmHg
pada 56%, dari ≥185mmHg pada 13% lainnya. Sebgian besar tekanan darah pasien menurun
secara spontan dalam 7 hari pertama setelah perawatan. Sehubungan dengan derajat
terganggunya autoregulasi serebral pada stroke akut maka peningkatan tekanan darah
mungkin bermanfaat untuk meningkatkan perfusi di area penumbra yang sedang iskemik.
Walaupun berisiko tekanan darh yang tinggi bisa memperburuk klinis dengan meluasnya
hematoma, edema serebri, hemorrhagic transformation (Dureshi Al, Ezzeddline)
Menurut guidlines American Heart Associaton (AHA) 2013 untuk pemeriksaan pasien
stroke iskemia akut, tekanan darah ideal selama periode akut belum dapat ditentukan
targetnya, tergantung pada faktor-faktor spesifik pasien. Bila pasien direncanakan sebagai
kandidat trombolisasi, tekanan darah sistolik diturunkan menjadi <185mmHg dan tekanan
darah diastol menjadi <110mmHg, dapat diberikan labetolol atau hidralazin intravena.
Jika tekanan darah berfluktuasi di dekat tekanan target, dapat diberikan nicardipin
atau clevidipin drip IV diharapkan tercapai tekanan darah sistolik <180mmHg dan tekanan
darah diastolik <105mmHg sebelum bolus rtPA diinfuskan. target ini direkomendasikan
dipertahankan selama 24 jam setelah rtPA. Monitor tekanan darah setiap 10-15 menit pada
jam pertama (Jauch EC, Saver)
Bila pasien tidak kandidat trombolisasi, AHA merekomendasikan untuk memulai
terapi antihipertensi kecuali bila tekanan darah sitolik >220mmHg atau tekanan darah
diastolik >120mmHg. AHA juga merekomendasikan boleh menurunkan tekanan darah
sebesar 15% selama 24 jam pertama setelah onset stroke. Target tekanan darah yang lebih
rendah sering dimulai pemberian antihipertensi jika ada bukti kerusakan target organ
disebabkan tekanan darah yang tinggi atau bila diperkirakan tekanan darah akan
memperburuk kondisi komodrbid.
Fig 4. Manajemen Tekanan Darah pada Stroke Akut
(MT. Mullen JS Mc Kimmy SE Kasnev)

Acut
e
Strok
e
Ischemic or
Hemorrhagic

Ischemic Hemorrhagic

Thrombolysis  If ICP is normal,

candidate? BP<160/90 at presentation
and no prior history of
HTN maintain BP 140/8
 If BP at presentation
Ye N >160/90 and/or there is a
s o prior history of HTN
maintain BP<160/90
 BP<185/110mm  If on beta blocker, and/or MAP<110mmHg
Hg prior to reduce dose by 50%  If ICP is increased,
thrombolysis  Hold all other pre- consider ICP monitor and
 Post-treatement existing maintain CPP 60-80
maintain antihypertensives mmHg
BP<185mmHg  If SBP>220, DBP>120,  Nicardipine continuous
 IV labetolol 10- or MAP>140mmHg infusion (5mg/hr initial
20mg or lover BP by no more dose) preferred
continuous than 15%
infusion of  IV labetolol 10-20 mg
nicardipine IV enalaprilat 1,25-2,5
(5mg/hr initial mg, or continuous
dose) preferred) infusion of nicardipine
(5mg/hr initial dose)
preferred
 Tabel 1. Trials of antihypertensive drugs and outcumes in acute ischemic stroke
Study Stake N Mean onset Inclusion BP and target BP Drug Mean BP Stroke Functional Comments
type time to reduction reduction in classific independence
randomizati treatment ation and
on (hours) group cerrebrovascular
events
ACCESS I: 100% 342 29,8 Mean SBP 6-24 hours after Candesart No NA No difference in Treatment
H: 0% admission ≥200mmHg or an significant barthel index at population
DBP ≥110mmHg reduction 3 months. No had higher
Mean SBP 24-36 hours difference in BPs than
after admission cerebrovascular other
≥180mmHg or DBP events at 12 studies
≥105mmHg months
Target 10-15% BP
reduction within 24 hours
PRoFESS I:100% 1360 58 Inclusion SBP 121-180 Telmisarta SBP Small No difference in Post-hoc
substudy H:0% mmHg and DBP≤110 n reduction artery mRS score at 30 analysis
mmHg 6,1 mmHg occlusio days or stroke Dysphasic
at 7 days n: 52% reccurrence at patients
and 5,8 Cardioe 90 days excluded
mmHg at 90 mbolic:
days 1,8%
SCAST I: 85% 2029 18 Inclusion SBP >140 Candesart SBP Lacunar No difference in Dose
 H: 14% mmHg an reduction infarct: mRS score or adjustments
Fixed dose escalation 5mmHg and 27% for stroke if SBP
schedule. No target DBP candesar recurrence at 6 <120mmHg
specified reduction tan 31% months or if
2mmHg on for clinically
day 7 placebo indicated
CHHIPS I: 86% 179 Treatment: Inclusion SBP >160 Oral SBP Lacunar No difference in Treatment
H: 14% 19,8 hours mmHg labetolol reduction infarct: death of discontinue
Placebo: Target SBP of145-155 (50mg), 14 mmHg 28% depedency rate d if
17,4 hours mmHg or 15 mmHg oral and DBP treatmen at 2 weeks SBP<140
decrease at 4 hours lisinopril eduction t and between mmHg
(5mg) or 7mmHg 16% treatment and within 8
placebo with placebo placebo hours of
lisinopril at drug
24 hours administrati
on
COSSAC I: 59% 763 23,6 hours Inclusion SBP <200mmHg Continuati SBP Lacunar No difference in No BP
S H: 5% afeter stroke and DBP <120mmHg on of reduction infarct: death or differences
onset and No target reduction home 13mmHg 38% dependency rate between
16 hours medicatio and DBP at 2 weeks control and
after last ns reductions 8 No difference in treatment
dose of mmHg at 2 stroke groups
 antihyperten weeks recurrence at 6 prior to 2
sive drug months weeks
CATTS I: 100% 4071 Treatment: Inclusion SBP 140- Predefined SBP Lacunar No difference Iv
H:0% 15,3 hours 200mmHg algorithm reductions infarct: ind eath or thrombolic
Control: Target SBP reduction 10- involving 8,1 and 9,3 treatmen disability rate at use in <3%
14,9 hours 25% at 24 hours ACE-I, mmHg and t 20,5% 14 days after of
Target BP<140/90 mmHg CCB, and DBP control randomization participants
at 7 days diuretics reduction 18,9% No difference in
3,8 and 4,0 mRS score at 3
mmHg at 24 months
hours and 7
days