Cardiology AdvisorEarly Management of Patients with AIS: A 2026 AHA/ASA Guideline Update

The AHA/ASA replaced 2018 stroke guidelines with expanded EVT and thrombolysis eligibility, now including basilar artery occlusion and large ischemic core patients previously excluded. Critically, aggressive BP lowering post-reperfusion and intensive glucose control are no longer recommended, reversing longstanding practice.

🩺 Clinical Considerations

• EVT now indicated for basilar artery occlusion within 24 hours with NIHSS ≥10, a major expansion from prior guidelines
• Large ischemic core volume no longer excludes patients from endovascular therapy based on improved functional outcome data
• Intensive glucose targeting (80–130 mg/dL) increases severe hypoglycemia risk without outcome benefit and is now contraindicated
• Systolic BP reduction below 140 mmHg post-thrombolysis or EVT shows no functional benefit and may cause harm after successful reperfusion

🎯 Practice Applications

• Update AIS order sets to remove intensive glucose and aggressive BP reduction targets post-reperfusion
• Review transfer protocols to ensure basilar occlusion patients reach EVT-capable centers within the 24-hour window
• Align cardiology and stroke team communication for AIS patients with concurrent cardiac conditions requiring BP management
• Incorporate mobile stroke unit partnerships into regional STEMI-equivalent response networks where available

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