2026 Southeastern Residency Conference

Title: Comparison of Nicardipine and Labetalol for Peri-Thrombolysis Blood Pressure Management in Acute Ischemic Stroke
Authors: Olivia Klassa, Braiden Sorgenfrei, Michael Wagner, Alex Ewing, Lauren McAbee 
Background:  
Acute ischemic stroke requires rapid thrombolytic therapy to restore cerebral blood flow and optimize outcomes; however, safe administration depends on effective blood pressure control. Current AHA/ASA guidelines recommend reducing blood pressure to less than 185/110 mmHg prior to tenecteplase and maintaining less than 180/105 mmHg for 24 hours after administration. Elevated blood pressure may delay thrombolytic administration and increase hemorrhagic risk. Labetalol and nicardipine are commonly used first-line agents, though limited evidence supports a preferred option. This study aims to compare labetalol and nicardipine for their impact on door-to-needle time and 24-hour blood pressure control in patients receiving tenecteplase for acute ischemic stroke. 
Methods:  
A retrospective chart review was conducted at an 864-bed academic medical center in Greenville, South Carolina, between January 1, 2021, and October 31, 2025. Adults with acute ischemic stroke who received tenecteplase and required pre-thrombolysis blood pressure management with nicardipine or labetalol were included. Eligible patients were identified using a report from the Get With The Guidelines–Stroke database. Patients with hemorrhagic stroke, pregnancy, or receipt of alternative antihypertensives were excluded. The primary outcome was door-to-needle time. Secondary outcomes included time to blood pressure control, 24-hour blood pressure variability, antihypertensive utilization, and clinical outcomes including bleeding, mortality, and functional and neurologic status. 
Results:  
A total of 100 patients met inclusion criteria and were included in the final analysis. Of these, 38 received labetalol alone, 25 received nicardipine alone, 31 required escalation from labetalol to nicardipine, and 6 required escalation from nicardipine to labetalol prior to TNK administration. Baseline characteristics were similar between groups, though the nicardipine group had a higher prevalence of hypertension and greater outpatient antihypertensive use. Median door-to-needle time was similar between groups (28 vs. 33 minutes, p=0.09), and a similar proportion of patients achieved a door-to-needle time less than or equal to 30 minutes. However, a greater proportion of patients receiving labetalol achieved door-to-needle times less than or equal to 15 minutes (15.8% vs. 0%, p=0.02). Door-to-CT times were also similar across groups. Time to blood pressure control differed significantly between strategies, with labetalol achieving faster control compared to nicardipine (4 minutes vs. 8 minutes, p=0.001). Patients requiring escalation between agents experienced longer times to blood pressure control. Blood pressure parameters during the first 24 hours, as well as safety and functional outcomes, were similar across treatment strategies. 
Conclusions:  
The findings of this study demonstrate that antihypertensive strategy prior to TNK administration did not significantly impact door-to-needle time in patients presenting with acute ischemic stroke. While labetalol achieved faster time to blood pressure control compared with nicardipine, this difference did not translate into meaningful differences in treatment timing or clinical outcomes. Safety and functional outcomes were also similar between treatment strategies. These findings should be interpreted in the context of the retrospective single-center design and small sample sizes.