Blood pressure management in stroke: comparative review of the 2025 AHA/ACC/AANP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM, 2024 ESC, 2023 ESH, and 2025 JSH guidelines

Hypertension is the primary modifiable risk factor for both ischemic stroke and intracerebral hemorrhage (ICH), yet recommendations for blood pressure (BP) management vary across contemporary guidelines. This narrative review compares BP targets and therapeutic strategies in the 2025 American Heart Association (AHA), 2024 European Society of Cardiology (ESC), 2023 European Society of Hypertension (ESH), and 2025 Japanese Society of Hypertension (JSH) guidelines, with emphasis on acute and chronic phases of ischemic stroke and ICH. In acute ischemic stroke without reperfusion therapy, all four guidelines discourage routine BP lowering unless systolic BP (SBP) is ≥220 mmHg or diastolic BP ≥ 120 (110) mmHg, and then recommend only modest reductions of about 15% within 24 hours. For patients receiving IV thrombolysis or mechanical thrombectomy, the guidelines converge on pre-treatment BP