It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke. IIb C-EO New recommendation. Patients with severe hypertension (most commonly >220/120 mmHg) were excluded from clinical trials evaluating BP lowering after AIS.244 249 Rapid BP reduction has traditionally been advised for these cases, but the benefit of such treatment in the absence of comorbid conditions that may be acutely exacerbated by severe hypertension has not been formally studied. Ideal management in these situations should be individualized, but in general, initial BP reduction by 15% is a reasonable goal. Excessive drop in BP could result in complications such as stroke progression (by compromising cerebral perfusion in penumbral tissue) and acute kidney injury (from renal hypoperfusion). There are no data to show that one strategy to lower BP is better than another after AIS. The medications and doses in Table 5 are all reasonable options. See Table LVI in online Data Supplement 1. 4. In patients with BP <220/120 mmHg who did not receive IV alteplase or mechanical thrombectomy and do not have a comorbid condition requiring urgent antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an AIS is not effective to prevent death or dependency. III: No Benefit A Recommendation revised from 2013 AIS Guidelines. Multiple RCTs and meta-analyses of these trials244 258 have consistently shown that initiating or reinitiating antihypertensive therapy within the first 48 to 72 hours after an AIS is safe, but this strategy is not associated with improved mortality or functional outcomes. However, none of these trials were designed to study BP reduction within the first 6 hours after stroke, and all excluded patients with extreme hypertension or coexistent indications for rapid BP reduction. 