Ahmed HM, Aimen UE. Esmolol in acute ischemic stroke thrombolysis: Benefits confined to atrial fibrillation and hypertensive patients. World J Clin Cases 2026; 14(17): 120665 [DOI: 10.12998/wjcc.v14.i17.120665]
Corresponding Author of This Article
Hafiz M Ahmed, MD, Department of Medicine, Punjab Medical College, Faisalabad Medical University, Sarogdha Road, Faisalabad 38000, Pakistan. mohammadahmed818@yahoo.com
Research Domain of This Article
Clinical Neurology
Article-Type of This Article
editorial
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Clin Cases. Jun 16, 2026; 14(17): 120665 Published online Jun 16, 2026. doi: 10.12998/wjcc.v14.i17.120665
Esmolol in acute ischemic stroke thrombolysis: Benefits confined to atrial fibrillation and hypertensive patients
Hafiz M Ahmed, Umm E Aimen
Hafiz M Ahmed, Umm E Aimen, Department of Medicine, Punjab Medical College, Faisalabad Medical University, Faisalabad 38000, Pakistan
Co-first authors: Hafiz M Ahmed and Umm E Aimen.
Author contributions: Ahmed HM and Aimen UE contributed equally to this work as co-first authors; Ahmed HM conceived the manuscript idea, developed the overall concept of the article, and supervised the project; Aimen UE contributed to the literature review and drafting of key sections. Both authors contributed to manuscript writing, critical revision for important intellectual content, and approved the final version of the manuscript.
AI contribution statement: AI tools (ChatGPT and Claude) were used in a limited capacity solely for language editing, including correction of grammar, punctuation, and improvement of clarity. These tools were applied only after the original manuscript had been written by the authors. AI tools were used only for minor language polishing and did not contribute to the scientific content, data analysis, or generation of results. AI tools did not contribute to the study design, methodology, or interpretation of findings.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Hafiz M Ahmed, MD, Department of Medicine, Punjab Medical College, Faisalabad Medical University, Sarogdha Road, Faisalabad 38000, Pakistan. mohammadahmed818@yahoo.com
Received: March 6, 2026 Revised: April 9, 2026 Accepted: May 11, 2026 Published online: June 16, 2026 Processing time: 89 Days and 15.4 Hours
Abstract
This editorial comments on the retrospective study by Papamichalis et al published in the recent issue of World Journal of Clinical Cases, examining esmolol use during the acute phase of ischemic stroke in 149 patients undergoing intravenous thrombolysis. The study raises a clinically important question: Does heart rate control with esmolol improve or worsen outcomes after thrombolysis? The findings challenge the routine use of esmolol in this setting. Current guidelines from the American Heart Association/American Stroke Association recommend lowering blood pressure to below 185/110 mmHg before intravenous thrombolysis, but provide no guidance on the preferred pharmacological agent. Esmolol, a short-acting beta-1 selective blocker, reduces cardiac output and may compromise cerebral perfusion pressure in patients with already compromised cerebrovascular autoregulation. The observation that esmolol was associated with poor outcomes in patients without atrial fibrillation or hypertension, yet appeared neutral in those with atrial fibrillation or established hypertension, suggests that underlying cardiac and vascular physiology significantly modifies drug response. This subgroup-dependent effect has direct clinical implications. Indiscriminate beta-blockade in the acute stroke window may be harmful, particularly in patients without a clear hemodynamic indication. These data support a personalized, indication-driven approach to blood pressure pharmacotherapy before thrombolysis, and highlight the urgent need for prospective trials in this underexplored area.
Core Tip: Esmolol, an ultrashort-acting beta-1 selective blocker, is increasingly used for pre-thrombolysis blood pressure control in acute ischemic stroke, but evidence for its safety in this setting is limited. In a study of 149 patients with acute ischemic stroke undergoing intravenous thrombolysis, Papamichalis et al report that esmolol-treated patients showed significantly worse 3-month functional outcomes, defined by modified Rankin Scale score > 2, compared with untreated patients. Subgroup analyses revealed that this harm was confined to patients without atrial fibrillation and those without a history of hypertension, while outcomes were not significantly different in patients with atrial fibrillation or established hypertension. These data support individualized antihypertensive selection and underscore the need for prospective trials in this underexplored but clinically critical area.
