Summary box: BP agents of choice in acute stroke

 Acute ischaemic stroke (AIS)Avoid large falls (>20%) in BP.
Aim for gradual BP reduction (5–15%).
 Intracerebral haemorrhage (ICH)Rapid lowering of BP to ≤140 mm Hg within 6 hours of onset.
 Intravenous agentsRequire continuous cardiac monitoring.
  Labetalol10–20 mg bolus, over 1–2 min. Further boluses can be given every 10 min, titrated to BP effect (maximum dose 300 mg).
Alternative: labetalol infusion.
  Glyceryl trinitrate10–200 μg/min infusion titrated to BP effect.
  NicardipineAvoid large BP falls in AIS.
5 mg/hour infusion titrated to BP effect.
  Sodium nitroprussideAvoid in ICH due to antiplatelet effects.
0.5 μg/kg/min initial dose, infusion then titrated to BP effect.
 Oral agentsSwallowing assessment required, up to 50% of patients dysphagic.
 Sublingual agentsRapidly absorbed, can cause steep falls in BP (limited data).
 Transdermal agentsGlyceryl trinitrate 5–10 mg/24-hour patch according to BP effect.