Hourly blood pressure monitoring after intravenous tissue plasminogen activator for ischemic stroke - Does everyone need it?

Background and Purpose - Blood pressure ( BP) control is considered essential in patients treated with tissue plasminogen activator (tPA) for ischemic stroke, and it is recommended that BP be monitored every 15 minutes to 1 hour for 24 hours in these patients. We postulated that patients whose BP is not initially elevated are unlikely to have elevated BP later and, therefore, may not need prolonged BP monitoring. Methods - We performed a retrospective chart review of patients treated with intravenous tPA for ischemic stroke over a 3-year period. Patients with incomplete records were excluded. Results - Seventy-nine patients ( 35 male, age 68.8 +/- 14.3 years) were studied. Before tPA treatment, 16 patients (20%) had hypertension ( systolic BP greater than or equal to 185 or diastolic BP greater than or equal to 110 mm Hg). All 16 patients had subsequent hypertension over the next 24 hours. Of the remaining 63, 27 patients (43%) had hypertension ( systolic BP greater than or equal to 180 or diastolic BP greater than or equal to 105 mm Hg) within the first 6 hours. An additional 4 had minor transient systolic elevations ( less than or equal to 182 mm Hg) after 6 hours that normalized without treatment. Neurological worsening, seen in 13 patients (17%), was not associated with the presence of hypertension ( initial or subsequent). Conclusions - In patients receiving tPA for stroke, absence of hypertension at presentation does not preclude subsequent increase in blood pressure. However, if blood pressure is not elevated during the first 6 hours, subsequent hypertension over the next 18 hours is unlikely. This study is small and retrospective, and needs to be repeated in a larger prospective cohort. However, our results provide preliminary evidence to suggest that where resources are scarce, these patients may be discharged from the intensive care unit earlier than the recommended 24 hours, provided that they are not at high risk for neurological deterioration.