Permissive hypertension refers to allowing blood pressure to remain high, which may offer some benefits after a stroke. However, this should only be done under medical supervision.

Permissive hypertension is a treatment approach a doctor may use after you’ve had an ischemic stroke. This is typically a stroke where you have a blood clot that prevents blood flow to a specific area of your brain. Under these circumstances, higher blood pressures may have brain-protective benefits.

After you’ve had an acute stroke, you’ll likely require hospitalization. During this time, healthcare professionals will carefully monitor your blood pressure to make sure your blood pressure doesn’t get too high.

Permissive hypertension isn’t usually an approach you’ll use outside the hospital. Keep reading to find out more about how permissive hypertension works, the risks, and its potential benefits.

Permissive hypertension is an approach where a doctor will hold or lower the dosages of blood pressure-lowering medications for up to 48 hours immediately following a stroke. As a result, a person’s blood pressure will usually be higher than ranges that are typically accepted.

Research hasn’t been fully conclusive that permissive hypertension is the best approach after a person has a stroke. However, some research studies have indicated that higher blood pressures may help to promote blood flow to the blood vessels in the brain, which may not have received blood during a stroke.

For good reason, your brain fits snuggly inside your skull. If it swells, there isn’t a lot of room to expand. Normally, as long as your blood pressure is in a certain range, your brain gets the blood flow it needs. If your blood pressure is too low, your brain may not receive enough blood. If your blood pressure is too high, your brain can swell, and bleeding risks are increased.

However, if you’ve had a stroke, your brain tissue can become damaged. The same rules and pressures it worked on before may not work as well this time. Instead, your brain can’t regulate blood flow as well, and you may need higher blood pressures to make sure your brain gets the blood it needs.

This concept is the underlying idea behind permissive hypertension. We’ll explore the potential benefits of higher blood pressure after stroke in the next section.

High blood pressure is a major contributing factor to stroke — and patients admitted with stroke often have higher than standard blood pressures. One of the reasons why blood pressure may be so high during a stroke is because the body is attempting to get more blood to the brain.

When a person has an ischemic stroke, they have a clot that’s blocking blood flow to an area of the brain. Think of this like a log falling across a stream, preventing water from flowing to the other side. The body tries to increase blood pressure as a way to get around the obstruction, much like if there was a significant increase in water flow, the water could go over the log.

The argument for keeping blood pressure high after a stroke has several reasonings. First, those who experience a stroke typically already have high blood pressures. Lowering their blood pressure too much could affect the way their body works because their bodies are used to “running” on higher blood pressures.

Second, the brain is trying to maintain or re-establish blood flow after it was blocked. Higher blood pressures are typically going to result in greater brain blood flow.

One study found that patients cared for at home after a stroke had more functional improvements than those cared for at an acute rehab facility after a stroke. The acute rehab facility controlled blood pressure more tightly, not allowing for as much permissive hypertension.

The researchers theorized that too-tight blood pressure controls after strokes negatively affected their return to function.

In 2019, the American Heart Association (AHA) released updated “Guidelines for the Early Management of Patients With Ischemic Stroke.” Included in these guidelines are blood pressure management recommendations. These recommendations depend upon how a doctor is treating the stroke.

The following chart illustrates the AHA’s blood pressure recommendations by treatment.

TreatmentBlood Pressure Recommendations
Intravenous alteplaseCareful lowering to less than 185 systolic and 110 diastolic before administering.
Mechanical thrombectomy (removing the clot)Keep blood pressure at 185/110 or less before the procedure.
Supportive treatments If they don’t have certain medical history (heart failure, coronary stent, or pre-eclampsia/eclampsia), initiate treatments if blood pressure is greater than 220 systolic or 120 diastolic.
The first goal should be to decrease blood pressure by about 15% of their pressure when they came to the hospital.

The AHA’s guidelines say the usefulness of drug-induced hypertension (giving medications to purposefully increase blood pressure) is “not well established.” Their guidelines also encourage doctors to study each patient and their medical history carefully before determining a blood pressure goal.

Always follow your doctor’s recommendations

Permissive hypertension recommendations are just that — a generalized recommendation. They aren’t meant for everyone to use.

If you or a loved one has had a stroke, following a doctor’s recommendations is the best plan.

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Permissive hypertension can present risks because extremely high blood pressure can increase a person’s risk of changing an ischemic stroke (due to a blood clot) to a hemorrhagic stroke. A hemorrhagic stroke is where an artery in the brain bursts and there’s significant bleeding in the brain.

Doctors won’t usually recommend permissive hypertension methods for poststroke care for those who have a left-ventricular assist device (LVAD). This device works to assist a heart that’s poorly functioning.

Research has also shown permissive hypertension can actually decrease (instead of increase) blood flow to the brain. As a result, permissive hypertension on a patient with an LVAD can be a potentially dangerous approach.

Permissive hypertension doesn’t have a special code or medication regimen for insurance or Medicare. Instead, temporarily stopping your blood pressure-lowering medications may be a part of your overall treatment after you’ve had a stroke.

When you’ve had time to recover from your stroke, your doctor may assess the medications you take to determine what you should continue taking and if you need new medications. You can review your insurance plan and Medicare benefits at this time to determine what medications they cover.

Caring for yourself after a stroke

Whether or not you experience long-term deficits after a stroke, knowing you had a stroke in the first place can be an overwhelming feeling. Some steps to help you care for yourself after a stroke include:

  • Ask a doctor if there’s a neurorehabilitation program in your area. These programs offer specialized services to help patients recover after a stroke.
  • Use the American Stroke Association’s Stroke Support Group Finder to locate a support group near you.
  • Evaluate your home for potential fall risks. After a stroke, you’re more at risk of falling. Make sure you have sturdy furniture, uncluttered floors, and slip-proof bathtub surfaces.
  • Get professional help from a counselor. The risks for depression are high after a stroke. Seeing a counselor sooner rather than later can help.
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Permissive hypertension may seem like an unusual approach after stroke. After all, it’s not often a doctor tells you not to take your medications. However, for the right patients, permissive hypertension may help improve stroke recovery.

Having higher blood pressure after a blood-clot-related stroke can sometimes be a way to help the brain restore blood flow. However, this will only be done while you’re under close observation in a hospital.

You shouldn’t stop taking your blood pressure medications under any other circumstances, unless a doctor directs you to do so. Talking with your doctor is the best way to understand your stroke recovery.